*Alcohol Units: 1 Pint Of Premium Beer = 2.5 Units. Total 1 Pint Beer/Cider = 2 Units. Single Measure Of Score Spirit = 1 Unit. Small (125ml) Glass Of Wine = 1 Unit Diet and Exercise What type of diet do you have? 6 How much exercise do you do? Healthy Unhealthy Sedentary (No exercise) Vegan Gentle (climbs stairs, walking , gardening) Vegetarian Moderate (Cycling, swimming regularly) Moderate Vigorous (Attends gym regularly) Please enter your height in Please enter your weight in Feet / inches: cm: Kilos/grams: Stones / lbs: Women Only What is the date of your last Smear test? Date: Result: 7 Yes Was this at your GP Surgery? Date of last Mammogram (if applicable): No 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 family Who: illness. Please state: under age of 60 Who: Who: Who: Please state any allergies and sensitivities you have to medicines, food & dressings: Please state any mental disabilities you have: Are you able to administer your own medicines? If no please give details, e.g. swallowing or opening Yes containers: No What long term medical conditions have you had? Date of Diagnosis: What operations or serious injuries have you had? Date of operations or injuries:
*Alcohol Units: 1 Pint Of Premium Beer = 2.5 Units. 1 Pint Beer/Cider = 2 Units. Single Measure Of Spirit = 1 Unit. Small (125ml) Glass Of Wine = 1 Unit Total Score 6 Diet and Exercise What type of diet do you have? How much exercise do you do? Healthy Sedentary (No exercise) Unhealthy Gentle (climbs stairs, walking , gardening) Vegan Moderate (Cycling, swimming regularly) Vegetarian Vigorous (Attends gym regularly) Moderate Please enter your height in Please enter your weight in Feet / inches: cm: Kilos/grams: Stones / lbs: 7 Women Only What is the date of your last Smear test? Date: Result: Was this at your GP Surgery? Yes No 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: Please state any allergies and sensitivities you have to medicines, food & dressings: Please state any mental disabilities you have: Are you able to administer your own medicines? Yes No If no please give details, e.g. swallowing or opening containers: What long term medical conditions have you had? Date of Diagnosis: What operations or serious injuries have you had? Date of operations or injuries:
CWHHE%20Adult%20New%20Patient%20Registration%20Form.docx