Tean Surgery

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)