Personal Details:	Date completed: _____________   Ethnicity   _______________  

Title: __________   Full Name:   ___________________________________________

Date of Birth __________   Any previous names?    ____________________________
  
Address ______________________________________________________________

__________________________________________ Post Code:-   _________________ 

Telephone ___________________       Mobile    ______________________________

NHS number (if known) _______________________________

If not British origin - how long have you been in this country?  ____________________
 
Marital Status - Single / Married / Divorced / Separated / Civil Partnership / Widowed 

Next of Kin   Name_________________ Relationship to you __________________

Contact Number  _______________________________________________________

Do you have someone who provides you with help and support (friend/partner /family member)?   YES / NO
	 
If YES and you are their “Registered Carer” please fill in the form enclosed in this pack

ALLERGIES

Are you allergic or sensitive to any medications, food, animals etc?

ILLNESSES, ACCIDENTS OR OPERATIONS

Please list all serious illnesses, accidents, hospital admissions or operations with dates and hospital attended-

CURRENT MEDICATIONS AND WHAT THEY ARE PRESCRIBED FOR :

LIFESTYLE

Do you Smoke?		YES / NO

Have you ever smoked 	YES / NO  

If YES when did you give up? _________________

If you are currently smoking – how many do you smoke a day _______________

Would like smoking cessation advice?  YES / NO

How much alcohol do you drink in an average week? ______________________

Do you take any regular exercise? (details) ______________________________

WEIGHT

Do you know your weight? ___________________________________________

HEIGHT

What is your height? _______________________________________________

OCCUPATION

What is your occupation? ____________________________________________

What jobs have you had in the past? ___________________________________

FAMILY HISTORY

Are your parents still alive and in good health?

Mother _______________________	Father ___________________________

Brothers and sisters and their ages?

Do you or any close relations have any of the following? (please give details)

Diabetes                                  YES / NO 	__________________________

High blood pressure     	     YES / NO 	__________________________

Heart Attack 	               	     YES / NO 	__________________________

Stroke		      	                YES / NO		__________________________

Epilepsy or fits		     YES / NO 	__________________________

Asthma 			     YES / NO 	__________________________

Skin Disease 		     YES / NO 	__________________________

Anxiety / Depression 	     YES / NO 	__________________________

Cancer 		                YES / NO		__________________________

Kidney Disease 		     YES / NO 	__________________________

Other 				     YES / NO 	__________________________

WOMEN ONLY

Contraception

Do you use any contraception? YES / NO    If yes what do you use? __________

If you are taking the pill, how long have you been taking it for?	___________

Do you get any side effects? __________________________________________

Cervical Smears

Have you had a cervical (cancer) smear?  YES / NO

If yes where was it performed? (Please circle answer):

Previous surgery / Private Clinic / Family Planning Clinic / Other 

(Please give name/address if possible): ____________________________

If yes approximately what date? ________________________________________