Coronavirus (COVID-19)
Old Road | Tean | Stoke-on-Trent | ST10 4EG | telephone: 01538 722 323 For the Dispensary telephone: 01538 722 215
Blythe Bridge Primary Health Care
Todays Date
First Name
Surname
Sex (required) MaleFemale
Address Postcode Telephone Number Date of Birth Place of Birth
ethnicity AfricanAsianAsian BritishBlackBlack BritishCaribbeanChineseMixedWhite
Marital Status SingleMarriedWidowedDivorcedLiving with partner
Occupation
Main Language Spoken
Do you have a sensory impairment (deafness etc) or disability? YesNone
Do you require an interpreter? YesNo
Do you have an assistance dog? YesNo
Do you have difficulty accessing our building? YesNo
Do you smoke? YesNoNever
If yes how many per day
Would you like help to stop? YesNo
If you are an ex-smoker how many did you used to smoke per day?
What year did you stop?
Do you drink alcohol? YesNoNever
If yes how many units per week (1/2 pint, one measure = 1 unit)?
How tall are you?
How much do you weigh?
If you feel you are over weight would you like any dietary advice? YesNo
How many times do you exercise each week? OnceTwiceThree timesFour or more
Due to the new registration process each new patient over the age of 14 must have a blood pressure/urine check. This can be done simply and only takes a few minutes with our Health Care Support Worker but if you suffer from any of the following you will need a slightly longer check-up with the Practice Nurse. Please select all of the following which apply to you:
Coronary heart disease (this includes angina and all heart problems) YesNo Hypertension (high blood pressure) YesNo Diabetes including dietary controlled YesNo Epilepsy YesNo Hypothyroidism YesNo Severe mental health problems YesNo Asthma or chronic obstructive pulmonary disease YesNo Stroke/TIA YesNo
Have you had any recent medical problems? If so what?
If you are on regular medication please bring your prescription request slip with you including any not prescribed by you previous doctor.
Do you have any known allergies? YesNo
Please list all other major illness you might have suffered in the past:
Is there a history in your immediate family (parents, brother or sister) of any of the following?
Heart attack: under 65 years of age: YesNo over 65 years of age: YesNo
Diabetes YesNo
Asthma YesNo
Stroke/TIA YesNo
High blood pressure YesNo
Breast cancer YesNo
Bowel cancer YesNo
Glaucoma YesNo
Are you the primary carer for a member of your family who has a disability or long term illness? YesNo
Do you have a carer yourself? YesNo
Have you, at any time, been a patient at the surgery in the past (temporary or permanent)? YesNo
Your Email (required)
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