New Patient Health Check Step 1 of 2 50% Personal DetailsNHS Number Optional Name First Middle Last Previous Surname (if applicable) Optional GenderPlease SelectFemaleMaleDate of Birth Day Month Year Email Enter Email Confirm Email Do you consent to be contacted Via email?Please SelectYesNoHome Telephone OptionalMobile NumberDo you content to be contacted via SMS?Please SelectYesNoText Messaging – The practice uses text messaging as a means of communication with patients as an efficient and cost effective method, to remind patients of their appointments and for inviting to reviews. Address Street Address Address Line 2 City Post code Previous Address Street Address Optional Address Line 2 Optional City Optional Post Code Optional Preferred Method of Communication No preference Telephone – Home Telephone – Mobile Email Letter Video Conferencing Other DetailsMarital Status Optional Country of Birth EthnicityPlease SelectWhite (UK)White (Irish)White (Other)Black CaribbeanBlack AfricanBlack OtherBangladeshiIndianPakistaniChineseOtherReligon OptionalPlease SelectC of ECatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah's WitnessNo ReligionOtherCommunication NeedsWhat is your main spoken language? Do you need an interpretor?Please SelectYesNoDo you have any communication needs? Do you have a learning disability?Please selectYesNoCarer DetailsDo you have a Carer?Please selectYesNoAre you a Carer?Please SelectYesNoIf you are a carer book for your free health check at your GP practice.Medical HistoryPlease confirm if you are :- Disabled (13VC5) Housebound (13CA) Bedbound (13C6) None Have you ever had, or do you have, any of the following conditions:- High Blood Pressure Diabetes Heart problems Stoke / TIA Epilepsy / fits Eczema Mental Illness Depression Asthma COPD Thyroid Hepatitis Cancer Deaf Blind Deaf/blind Uses hearing aid Sign Language Makaton sign Lip reads Other None Other – Please Specify Please list any serious illness or operations (with dates were possible) OptionalFamily HistoryDoes anyone in your family have any history of the following: High blood pressure Diabetes Heart disease (under 59 years) Heart disease (60 years plus) COPD Asthma COPD Breast Cancer None AllergiesPlease record any allergies or sensitivities MedicationPlease list any medications you currently takeMedicationDoseHow often Add Remove Your LifestyleHow many times a week do you exercise and what type of exercise? AlcoholPlease answer the following questions which are validated as screening tools for alcohol use: AUDIT–C QUESTIONS Please check the correct boxes and check your score. (Scores can be found to the right of your answer)How often do you have a drink containing Alcohol?Please SelectNever (0)Monthly or Less (1)2-4 times per month (2)2-3 times per week (3)4+ times per week (4)UnitsPlease Select1-2 (0)3-4 (1)5-6 (2)7-9 (3)10+ (4)How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?Please selectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4) A score of less than 5 indicates lower risk drinking Scores of 5 or more require the following 7 questions to be completed:Total Score: 4 or less 5 or more How often during the last year have you found that you were not able to stop drinking once you had started?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you failed to do what was normally expected from you because of your drinking?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you had a feeling of guilt or remorse after drinking?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you been unable to remember what happened the night before because you had been drinking?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)Have you or somebody else been injured as a result of your drinking?Please SelectNo (0)Yes, but not in the last yearYes, during last yearHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?Please SelectNo (0)Yes, but not in the last yearYes, during last yearTotal Score? SmokingDo you smoke?Please SelectNever Smokedex SmokerYesE-CigaretteHow many cigarettes did/do you smoke a day? Would you like help to quit smoking? For further information, please see:www.nhs.uk/smokefreeHeight and WeightHeight Weight Women's HealthDo you use any contraception?Please SelectYesNo (If needed book an appointment)Are you currently pregnant or think you may be?Please SelectYesNoExpected due date Day Month Year Date of last smear: Optional Do you perform self-breast examination ? Yes No Male HealthDo you perform self-testicular examination? Yes No Electronic PrescribingIf you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional PPG – Patient Participation GroupWould you like to be involved in our Patient Participation Group?Please selectYesNoYour Summary Care Record (SCR)Summary Care records If you are registered with a GP practice in England you will have a Summary Care Record (SCR), unless you have previously chosen not to have one. It includes important information about your health: Medicines you are taking Allergies you suffer from Any bad reactions to medicines You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having an SCR means that when you need healthcare you can be helped to recall vital information. SCRs can help the staff involved in your care make better and safer decisions about how best to treat you. You can choose to have additional information included in your SCR, which can enhance the care you receive. This information includes: Your illnesses and health problems Operations and vaccinations you have had in the past How you would like to be treated – such as where you would prefer to receive care What support you might need Who should be contacted for more information about you Please notify the administration team if you do not want to participate in the method of communication in order that your records are updated. Name OptionalThis field is for validation purposes and should be left unchanged.
