the last last year year Yes, Yes, but Has a relative or friend, doctor or other health worker been concerned about not in No the your drinking or suggested that you cut down? the last last year year AUDIT Score (Questions 1 10): – Scoring: 0 7 Lower risk, 8 15 Increasing risk, 16 19 Higher risk, 20+ Possible dependence. – – – What is the date of your last Smear test? Women Only Date: Result: (Also known as a PAP or Cervical smear) 7 NHS Yes Was this at your GP Surgery? Please specify who processed your Smear test : Private No Abroad Date of last Mammogram (if applicable): Number of pregnancies (include miscarriages & terminations) (If applicable) Yes Do you wish to see a doctor in this Practice for contraceptive services (including the pill, coil or cap)? No Your Medical Background 8 Are there any serious diseases that affect your parents, brothers or sisters? Tick all that apply and state family member: Diabetes Asthma Thyroid disorder Stroke COPD Who: Who: Who: Who: Who: Attack Cancer (Specify type) High Blood pressure Any other important Who: family illness. Please under age of 60 Who: Who: state: Who:
the last year last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, the last year AUDIT Score (Questions 1 – 10): Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence. 7 Women Only What is the date of your last Smear test? (Also known as a PAP or Cervical smear) Date: Result: Was this at your GP Surgery? Yes No Please specify who processed your Smear test : NHS Private Abroad Date of last Mammogram (if applicable): Number of pregnancies (include miscarriages & terminations) (If applicable) Do you wish to see a doctor in this Practice for contraceptive services (including the pill, coil or cap)? Yes No 8 Your Medical Background Are there any serious diseases that affect your parents, brothers or sisters? Tick all that apply and state family member: Diabetes Who: Asthma Who: Thyroid disorder Who: Stroke Who: COPD Who: Attack under age of 60 Who: Cancer (Specify type) Who: High Blood pressure Who: Any other important family illness. Please state: Who: