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Park Leys Medical Practice

New Patient: Additional Information

Thank you for requesting registration with to Park Leys Medical Practice. We will contact you shortly to confirm that your registration has been successful. It is most unlikely that your request wil be declined unless your address is outside our practice area or there is a problem with the data you have submitted.

Once your registration has been confirmed you will be invited to a New Patient Interview with a Practice Nurse or Healthcare Assistant. This is to enable the practice to determine basic information about your health and care needs so that we are able to deliver a high quality service in keeping with your expectations. It is not used to determine your suitability to register with the practice.

We would ask you to complete and submit the form on the right which will save time at the New Patient Interview and enable us to start providing an effective service immediately.

Some of the data submitted will be used, in non identifable form, for demographic and epidemiological purposes by the NHS, the Primary Care Trust and the practice to tailor health care delivery to local needs.

Should your registration application be rejected this information will not be used but destroyed.

Alternatively click here to download a form for completion and submission to reception at any time prior to, or at the time of, your New Patient Interview.

Title*:

Surname*:

First Names*:

Date of Birth*:

Email*:

Carer*:

Smoking Status*:

If Smoker or Ex Smoker please supply details:

If Ex smoker when did you give up:

Do you drink alcohol*:
Yes
No

If Yes, how many units per week. ( 1 unit = one small glass of wine, half pint of beer or a small measure of spirits):

If you have any allergies, significant illnesses or are currently taking medication please give brief details.:

Have your father or brother had a stroke, heart attack or angina when aged under 55*:
Yes
No
Not known

Have your mother or sister had a stroke, heart attack or angina when aged under 65*:
Yes
No
Not known

Do/Did your mother, father, brother or sister suffer from any other heart disease*:
Yes
No
Not known

Do/Did your mother, father, brother or sister suffer from asthma*:
Yes
No
Not known

Do/Did your mother, father, brother or sister suffer from diabetes*:
Yes
No
Not known

Do/Did your mother, father, brother or sister suffer from breast cancer*:
Yes
No
Not known

Do/Did your mother, father, brother or sister suffer from bowel cancer*:
Yes
No
Not known

Have you had a cervical smear test (Female Patients Only):
Yes
No

Date of last cervical smear test (Female Patients Only):

Where was your last cervical smear carried out (Female Patients only):

Result of last cervical smear test (Female Patients Only):

What form of contraception do you use, if any (Female Patients Only):

To which of the following etnic groups do you belong*:

If other ethnic group please specify:

Conditions of Processing:

This message is processed on the basis that the patient consents for this information to be transmitted by email and accepts that confidentiality cannot be guaranteed.

I agree I do not agree

Last Updated 22nd May 2009