Your Ethnic Origin: White () White (Irish) White (Other) (select one) 9i0 9i1% 9i2% African Other Mixed Asian 9i5 9i3 9i4 Background 9i6% Indian / Pakistani / Bangladeshi / Brit Other Asian Brit Indian 9i7 Brit Pakistani 9i8 Bangladeshi 9i9 Background 9iA% Other Black Chinese Other Ethnic Category Background 9iE 9iF% not stated 9iG Your main or 1st language English Hindi Guajarati Urdu Bengali Punjabi /Sylheti Spoken / Understood: (select one) Polish Ukrainian French German Spanish (Please Specify) Smoking, Alcohol Consumption and Exercise: Yes No Yes No Are you currently a Have you ever been a smoker? smoker? How much alcohol do you drink in a If so, how many cigarettes / cigars / week (Units)? tobacco do you smoke in a week? (One unit = 1 glass of wine, a If you are a smoker and want to stop, please ask for single measure of spirits, or 1/2 a pint information about local smoking cessation services. of beer) No. per week Type(s) of How often do you exercise? exercise: Your Medical Background: What illnesses have you had & When? What operations have you had and When? Do you have any medical problems at present? Please list any tablets, Please attach your repeat slip if available. medicines or other treatments you are currently taking: (incl. dose + frequency) Are you able to administer your own Yes No please detail specific issues (e.g. swallowing, opening containers) – medicines?
Your Ethnic Origin: (select one) White () 9i0 White (Irish) 9i1% White (Other) 9i2% 9i3 African 9i4 Asian 9i5 Other Mixed Background 9i6% Indian / Brit Indian 9i7 Pakistani / Brit Pakistani 9i8 Bangladeshi / Brit Bangladeshi 9i9 Other Asian Background 9iA% Other Black Background Chinese 9iE Other 9iF% Ethnic Category not stated 9iG Your main or 1st language Spoken / Understood: (select one) English Hindi Guajarati Urdu Bengali /Sylheti Punjabi Polish Ukrainian French German Spanish (Please Specify) Smoking, Alcohol Consumption and Exercise: Are you currently a smoker? Yes No Have you ever been a smoker? Yes No If so, how many cigarettes / cigars / tobacco do you smoke in a week? How much alcohol do you drink in a week (Units)? (One unit = 1 glass of wine, a single measure of spirits, or 1/2 a pint of beer) If you are a smoker and want to stop, please ask for information about local smoking cessation services. How often do you exercise? No. per week Type(s) of exercise: Your Medical Background: What illnesses have you had & When? What operations have you had and When? Do you have any medical problems at present? Please list any tablets, medicines or other treatments you are currently taking: (incl. dose + frequency) Please attach your repeat slip if available. Are you able to administer your own medicines? Yes No – please detail specific issues (e.g. swallowing, opening containers)
NEW-PATIENT-REGISTRATION-Revised.docx