Welcome to Dalston Medical Group
Please fill in the following questionnaire to help us gather as much information as possible to help with your future care.
All information is strictly confidential
Full Name		
Date of Birth		
Country of Birth		
Ethnic group (i.e. White British,( ) White Irish.( ) - Mixed White and Black Caribbean( )  White & Asian ( ).- Asian or Asian British ( ) Pakistani ( ) Indian ( ).Black or Black British ( ) Caribbean, African.-Chinese ( .)	
First Language		
Telephone numbers
Home
Mobile
	
1.
2	
E-mail address		
Marital status		
Next of kin details	Name
Address

Relationship	
Who can we contact in an emergency?	Name:
Contact Number:
	
Emergency  access 	i.e key safe details	
Do you give a nominated person permission for the GP to discuss your medical records with ?	If yes please state who

	
Do you require any special requirements ?	i.e large print etc , interpreter etc	

Family History

	Age 	Any serious illness (stroke, heart disease, cancer etc)	If dead, cause of death	
Father				
Mother				
Brothers				
Sisters
				
Husband/ Wife/ Partner				
Children
				
What is your present occupation?
	
What is the occupation of your husband/wife/partner?

Are You A Carer?
A Carer is someone of any age who provides unpaid support to family or friends who could not manage without this help. This could be caring for a relative, partner or friend who is ill, frail, disabled or has mental health or substance misuse problems.
Carers: Do you need / have anyone who looks after you or your daily needs as a Carer?  Yes [  ] No [  ]	
	
Do you care for anyone else?  Yes [  ] No [  ] if yes please give details	

If yes, ask at reception for carers support	
Alcohol intake per week?   YES / NO
Total intake =
(1 unit  = 1 glass of wine, ½ pint of beer, pub measure of spirits)

Diet: Do you have a balanced diet? (milk, meat, veg & fruit)  
Do you add salt to your cooking? 

Do you Smoke?
How many?
What age did you start smoking?	
Do you take regular exercise?            If yes: How many minutes per session?       How many times per week:  one [  ] two  [  ] three [  ]	
Height:	Weight:	

Have you ever had any of the following:	
Tuberculosis [  ] Diabetes [  ] High Blood Pressure [  ] Heart Attack [  ] Stroke [  ] Asthma [  ]  Hay fever [  ]  Migraine [  ]  Depression [  ]  
Cancer [   ]  Epilepsy [   ]	
If so please give details below:	

		

Have you been immune against the following?	
Diphtheria [  ]  Tetanus [  ]  Polio [  ]  HiB (haemophilus) [  ] BCG [  ]
Whooping Cough [  ]  MMR (Measles Mumps Rubella) [  ]  Meningitis [  ]
Typhoid [   ]  Hepatitis A [   ]  Cholera  [   ]  Hepatitis B [   ] 	
Past Illnesses	
What illnesses have you had in the past                        Please indicate date	

What operations have you had or any hospital treatment?                                       Please indicate date	

	
	
What illnesses do you have at present?	

	
Give dates of any X-ray, MRI or CT scans, Ultrasound:	

Medications
Please list below the names of any medication that has been prescribed by your previous Doctor. If you have a repeat prescription card please enclose this instead
Name 	Dosage	How often do you take it	

	

	

Allergies please list below any allergies you have including medication, substances and food.	

 Ladies

Please list all pregnancies and miscarriages below:	
Date	Any complications of pregnancy?	Birth weight	

					
					
Date	How many weeks at miscarriage?	

					
Have you had a mammogram? Yes [  ] No [  ]	
When did you last have a cervical smear?	
Date		Was it normal? Yes [  ] No [  ]	
Are you using any of the following contraception	
Pill [  ]	Injection [  ]	Coil [  ]	Sterilization [  ]	

Please list below any additional information the doctor should know

	

We use a number of ways to remind patients of appointments and annual reviews either by mobile / e-mail / telephone / letter
If you do not wish to receive text or e-mails to remind you of your future appointments please tick the box 
Thank you for your co-operation
Patient / guardian signature 
………………………………………………………………..
Date
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Please note if any of your personal details change, please inform the surgery so we can keep your details up to date……thank you.