Personal Details Title (optional)—Please choose an option—MrMissMrsMsOther Name * Date of Birth * Previous Surname (optional) Postcode * Home Number (optional) Mobile Number * Email Address * Address * Additional Information What is your height? What is your weight? What is your first language? Do you need an interpreter?YesNo Ethnic Group Ethnic Group—Please choose an option—White BritishWhite IrishWhite OtherBlack BritishBlack CaribbeanBlack AfricanBlack OtherAsian IndianAsian PakistaniAsian ChineseAsian OtherWhite & Black BritishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther Please enter details here Previous GP & Identity Name and Address of Previous GP Identity Document Type—Please choose an option—Birth CertificateDriving LicencePassportUtility BillAllowance BookSolicitors LetterOffer of TenancyOther Please enter details here Other (optional) Medical History Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place (optional) Have you ever suffered from? (tick as appropriate) (optional)EpilepsyBlindness/GlaucomaHigh Blood PressureDiabetesHeart Attack/StrokeDepressionCancerAsthmaEczema/Hay FeverCOPD If yes, please state the year(s) when were you first diagnosed? (optional) Please list any medicines being taken and the amount (optional) Disability & Allergies Are you registered disabled?YesNo Are you allergic to any medicines?YesNo If yes, please give details (optional) If so, which? (optional) Treatment & Screening Have you ever refused treatment/screening of any kind?YesNo If so, what and when? (optional) Mental Health Have you ever suffered from? (tick as appropriate) (optional)AnxietyOCDDepressionBipolar Disorder If yes to any of these, please state the year(s) when were you first diagnosed? (optional) Do you have any other mental health issues?YesNo Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it) (optional) Carer Information Do you have a carer?YesNo Are you a carer?YesNo If yes please give details (optional) If yes please give details (optional) Women's Health Have you ever had a cervical smear?YesNo Do you hold a Living Will?YesNo If 'yes', please state when, where and the result (optional) Smoking Do you smoke?YesNo If 'No', have you ever smoked?YesNo Would you like advice on giving up smoking?YesNo If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? Alcohol MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?—Please choose an option—NeverLess than monthlyMonthlyWeeklyDaily How often during the last year have you failed to do what was normally expected of you because of drinking?—Please choose an option—NeverLess than monthlyMonthlyWeeklyDaily How often during the last year have you failed to do what was normally expected of you because of drinking?—Please choose an option—NeverLess than monthlyMonthlyWeeklyDaily In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?—Please choose an option—NoYes, on one occasionYes, more than once Family History Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. Next of Kin Please give name, address, telephone number and relationship of next of kin Vaccinations Have you had a flu vaccination? Enter date or 'never': Have you had a pneumococcal vaccination? Enter date or 'never' Contact Preferences Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.YesNo Declaration Signature Date