………………………………………………………………………………………………… Do you take regular exercise? Yes/No (If yes, please detail): ………………………………… Family History Have any close family members suffered from (please include relation, approx. age at diagnosis or age at death): Asthma: High Cholesterol: …………………………. ………………………… Diabetes (Inc type): Cancer (please specify type): ………………… ………… Heart Trouble: Stroke: …………………… ……………………………………. High Blood Pressure: ………………………… & Treatment If you are taking any drugs or treatment Inc. Contraception for women, please detail below: Name of medicine Strength Dose/day …………………………………. …………. ………… Name of medicine Strength Dose/day …………………………………. …………. ………… Name of medicine Strength Dose/day …………………………………. …………. ………… Name of medicine Strength Dose/day …………………………………. …………. ………… Please advise which Pharmacy you would prefer to collect your prescriptions from: Lowick Boots Lark Rise Do any medicines disagree with you? YES/NO If yes, which ones? ………………………… Do you have any allergies? YES/NO If yes, please detail what/reaction. ………………………………….... ADULTS: Have you had a course of tetanus injections/tetanus boosters in the last 10 years? YES/NO If yes, please give date ………………… Ethnic Group British Bangladeshi Irish Any other Asian background Any other White background & Black African White & Black African Any other Black background White & Asian Chinese Any other mixed background Any other ethnic group Indian Pakistani Do not wish to answer
………………………………………………………………………………………………… Do you take regular exercise? Yes/No (If yes, please detail): ………………………………… Family History Have any close family members suffered from (please include relation, approx. age at diagnosis or age at death): Asthma: …………………………. High Cholesterol: ………………………… Diabetes (Inc type): ………………… Cancer (please specify type): ………… Heart Trouble: …………………… Stroke: ……………………………………. High Blood Pressure: ………………………… & Treatment If you are taking any drugs or treatment Inc. Contraception for women, please detail below: Name of medicine …………………………………. Strength …………. Dose/day ………… Name of medicine …………………………………. Strength …………. Dose/day ………… Name of medicine …………………………………. Strength …………. Dose/day ………… Name of medicine …………………………………. Strength …………. Dose/day ………… Please advise which Pharmacy you would prefer to collect your prescriptions from: Lowick Boots Lark Rise Do any medicines disagree with you? YES/NO If yes, which ones? ………………………… Do you have any allergies? YES/NO If yes, please detail what/reaction. ………………………………….... ADULTS: Have you had a course of tetanus injections/tetanus boosters in the last 10 years? YES/NO If yes, please give date ………………… Ethnic Group British Bangladeshi Irish Any other Asian background Any other White background & Black African White & Black African Any other Black background White & Asian Chinese Any other mixed background Any other ethnic group Indian Pakistani Do not wish to answer
New%20Patient%20Form%20-%20updated%20Jan%202018.docx