Surname:    

Title:

Forenames:

Address:

Postcode:

Telephone no:

Status: Single / Married / Separated / Divorced / Widowed

/ Other

Occupation:

Housing: House / Flat / Maisonette / Mobile Home / Other

Who lives with you?

What Serious illnesses have you had?

What operations have you had?

Do you have any medical problems at the moment?

Please list any allergies you have:

Please list any tablets, medicines or other treatments you are taking including any bought from a chemist:

Are there any serious illnesses affecting your family?

(Women only)

When did you last have a breast scan?

When did you last have a cervical smear?

Did your previous GP or one of the GP’s staff take it?

Which immunisations have you had?  Please give dates if possible.

Diptheria

Measles

Tetanus

Measles / Mumps / Rubella

Pertussis (Whooping Cough)

Rubella (German Measles)

Polio

Other

Do you smoke?              Yes / No

How Many?

How  much  alcohol  do  you drink  each