APPLICATION TO JOIN VALLEYFIELD MEDICAL PRACTICE DR LESLEY PRENTICE

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APPLICATION TO JOIN

APPLICATION TO JOIN

VALLEYFIELD MEDICAL PRACTICE

Dr Lesley Prentice, Dr Jacqueline Sharp

PLEASE COMPLETE IN BLOCK LETTERS

When handing in the completed application form you must provide 2 forms of identification, eg birth or marriage certificate, passport , driving licence, ID card, Utility bill etc. One of the forms of identification must show your new address.

If you wish to have a new patient medical screening please ask when you return the forms and an appointment will be made with one of our Practice Nurses. We would recommend this if you have a complex medical history, multiple chronic conditions or if it is more than 3 years since you attended your GP

I wish to apply to register as a permanent patient

Signature………………………………….. Date………………………………

SURNAME …………………………………….. FIRST NAME(S) …………………………………….

Mr/Mrs/Ms/Miss DATE OF BIRTH :………………… MARITAL STATUS …………………

ADDRESS………………………………………………………………………………………………

Phone No………………… Works Phone No………………. Mobile No.………………………

Please give details below of your Next of Kin:

Name…………………………………… Relationship …………………………… Tel. No…………………….

……………………………………………………………………

Have you been registered with this Practice before? YES/NO

Was the house you moved in to empty? YES/NO

If NO, please give the name of the person already living in the house.

……………………………………………………………………………

Do you have any allergies? YES/NO

If Yes , please give what allergic to and type of reaction caused by allergy

…………………………………………………………………………………………………………………….

Do you take any medication or inhalers? YES/NO

If yes please attach an up-to-date repeat order form from your previous practice.

If you have any medications/inhalers etc not on your repeat order form please give details below

Drug Name Strength Dosage

………………………………. ……………………….. ………………………

Are you suffering from any medical conditions? YES/NO

If Yes please give details below

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Are you having any treatment at present? YES/NO

If Yes please give details below

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Have you had any serious illness or operations in the past? YES/NO

If Yes please give details below

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Do any illnesses run in your family? YES/NO

(ie Parents, Grandparents, Sisters, Brothers, Cousins etc.) eg. asthma, eczema, hayfever, diabetes, epilepsy, heart disease

Illness……………………………………………………………………………………………………

Relationship ………………………………………………………………………………………….…

What immunisations have you had? (Please include holiday vaccinations)

……………………………………………………………………………………………………………………...

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Are you employed at present? YES/NO

If yes, what is your occupation?......................................................................................................

Are you a carer? YES/NO

If yes, the person you care for and their relationship to you

……………………………………….................................................................................................................

Do you have a carer? YES/NO

If yes, name of carer and relationship to you

…………………………………………………… ………………………………………………………..

Would you like us to refer you to Fife Carers Centre to see what support they offer? YES/NO

Do you participate in any form of exercise? YES/NO

If yes please give details below

……………………………………………………………………………………………………………………

Do you smoke? YES/NO

If yes, how many per day ………

Have you ever smoked? YES/NO

If you are a smoker would you like advice about stopping smoking? YES/NO

We have a smoking cessation clinic, please ask at reception if you wish to make an appointment

Do you drink alcohol? YES/NO

If yes, please state how many Beer per week ……….

Spirits per week ……….

Wine per week ………

EMERGENCY CARE SUMMARY Consent to share information YES/NO

This is a summary of basic information about your health which might be important if you need urgent medical care when your GP surgery is closed. NHS24, Out of Hours Centres and Accident and Emergency Departments can look at your Emergency Care Summary on a computer it they need to treat you. What will be in my Emergency Care Summary?

Your name
Your date of birth
The name of your GP surgery
An identifying number called a CHI number
Information about any medicines prescribed by your GP surgery
Any bad reactions you’ve had to medicines that your GP know about.

Please ask at reception if you need more information.

ETHNIC ORIGIN

White Scottish (9S13) .……… White English (9i20) ……..…..

White Welsh (9i22) ……… White Northern Irish (9i24)…..…….

White British (9S10) …..….. White Irish (9S11) ………….

White Polish (9i2F) .……… White Gypsy/Traveller (9i2E) ………

Any other White ethnic group (9S12) ...................

Any mixed or multiple ethnic group (9SB) ………

Pakistani, Pakistani Scottish or Pakistani British (9S7) ………

Indian, Indian Scottish or Indian British (9S6) ………

Bangladeshi, Bangladeshi Scottish or Bangladeshi British (9S8) ……….

Chinese, Chinese Scottish or Chinese British (9S9) ………..

Any other Asian background (9SH) …………

African, African Scottish or African British (9S3) ………..

Caribbean, Caribbean Scottish or Caribbean British (9S2) ………..

Black, Black Scottish or Black British (9S41) ……….

Other Black background (9S4) ………..

Arab or other ethnic group (9SJ) ……….

Ethnic group not given – patient refused (9SD) ……….

INTERPRETER REQUIRED YES/NO

Interpreter needed - language (9NU%) ……………………………………………..

Interpreter needed – sign language BSL (9NUw) ……………………………………

WOMEN ONLY

When was your last cervical smear? ……………………………………………………………

Have you had a hysterectomy? …………………………………………………………….

Are you pregnant? ……………………………………………………

How many children have you had? ……………………………………………………..

Have you had other pregnancies …………………………………………………….

What method of contraception do you use? …………………………………………………….

If applicable do you wish to receive contraceptive services?

Pill, coil, diaphragm, injection, sheath, other ……………………………………………………..

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23 DATE FEBRUARY 23RD 2009 SUBJECT APPLICATION

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