The Guildhall and Barrow Surgery

Pre-registration Form
We should be grateful if you would provide us with as much information as possible. The practice treats all information it receives with the utmost confidence and no details will be passed to any other person or agency.

First name: Middle names:
Last name: Previous last name:
Date of birth: Gender: Male/Female
Ethnic origin: First language:
Single/Married/Partner/Separated/Widow Occupation:
Address:



Post code:
Telephone: Home:                               Work:                               Mobile:
Next of kin:
Next of kin address:


Next of kin telephone number:

Previous address:


Post code:
Previous doctor and address:

 
Town and country of birth:
If from overseas, date you came to the UK:

List any medications you are taking:

 

 
Do you have any allergies?
Do you smoke tobacco? Yes/No
If No, have you ever smoked?  Yes/No		 If Yes, what do you smoke?
How many/much per day?

 

Alcohol units: Pint of regular beer/lager/cider
2		 Alcopop or can of lager
1.5		 Glass of wine
175 ml.
2		 Single measure of spirits
1		 Bottle of wine
9
Questions Scoring system Your score
0 1 2 3 4
How often do you have a drink that contains alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week  
How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+  
How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily  
Scoring: A total of 5+ indicates hazardous or harmful drinking
Height: Weight:

FOR WOMEN
When did you last have a cervical sample taken?
Do you use contraception? If so, what type?
Date of last mammogram (if any):

Please give details of any significant illnesses or injuries you have had, giving dates.


 
Please give details of any significant illnesses that exist in your family.

 

Is there anything else you think we should know?

 

Signed: Date:

Please complete this form before you attend the surgery to register.  If you have a medical card, please sign this in the correct place and bring this with you.  If you do not have a medical card, you will be asked to complete and sign a form of registration.
Thank you.  We look forward to you joining the practice.
The Guildhall and Barrow Surgery.