Ashbourne Medical Practice New Patient Registration Form

PLEASE LIST ANY SERIOUS ILLNESSES / OPERATIONS / ACCIDENTS / DISABILITIES AND THE YEAR THEY TOOK PLACE

WHAT IS YOUR HEIGHT? *

WHAT IS YOUR WEIGHT? *

PLEASE LIST ANY ALLERGIES

DO YOU HAVE ANY PARTICULAR CONCERNS ABOUT YOUR HEALTH?

PLEASE LIST ANY REGULAR MEDICATIONS

ARE YOU CURRENTLY UNDER ANY HOSPITAL CARE? IF SO PLEASE SPECIFY

PLEASE LIST ANY IMMUNISATIONS RECEIVED

DO YOU HAVE A CARER? *

Yes No

IF YES, PLEASE PROVIDE THE NAME OF YOUR CARER

ARE YOU A CARER? *

Yes No

IF YES, PLEASE PROVIDE THE NAME OF THE PERSON YOU CARE FOR

HAVE YOU EVER HAD A CERVICAL SMEAR?

Yes No

IF YES, PLEASE PROVIDE THE DATE AND RESULT OF YOUR LAST CERVICAL SMEAR

HAVE YOU EVER HAD A MAMMOGRAM (BREAST XRAY)

Yes No

IF YES, PLEASE PROVIDE THE DATE AND RESULT OF YOUR LAST MAMMOGRAM

CONTRACEPTION METHOD (IF USED)

DO YOU HAVE A COIL OR CONTRACEPTIVE IMPLANT?

Yes No

IF YES, PLEASE PROVIDE THE DATE IT WAS FITTED

DO YOU DRINK ALCOHOL? *

Yes No

IF YES, HOW MANY UNITS OF ALCOHOL DO YOU DRINK PER WEEK? (One unit is half a pint of beer, a single spirit or a small glass of wine)

HAS YOUR MOTHER, FATHER OR SIBLING(S) HAD ANY OF THE FOLLOWING CONDITIONS

Heart attack under the age of 60

Raised blood pressure

Stroke

Diabetes

Cancer

Other

Summary care record

A summary care record contains an overview of your significant medical history, including any medications you take; any allergies you have; any adverse reactions you have experienced. Summary care records are used by external healthcare organisations such as out of hours services, walk in centre, A&E departments and paramedics. Without your consent, your summary medical record cannot be viewed by healthcare organisations and this could impact on your medical care.

Consenting to a summary care record also permits the practice to view medical information added by external healthcare professionals.

Additional communication requirements

Communication consent

DO YOU CONSENT TO THE PRACTICE CONTACTING YOU BY TEXT MESSAGE AND/OR EMAIL FOR THE PURPOSES OF APPOINTMENT REMINDERS, HEALTH PROMOTION AND PRACTICE NEWS? *

Yes No

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Ashbourne Medical Practice New Patient Registration Form

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