Contact Details
 
Title ……………………………………………………..	

Surname ………………………………………………..

First Names ……………………………………………

Previous Surnames …………………………………..

Home Address (we only accept registrations from M41 Postcode)

   
                                      Postcode: M41	

Date of Birth ……………………………………………

Home Tel ……………………………………………….

Mobile Number …………………………………..........

Email Address …………………………………………

Can we contact you by Text Message?   
  Yes 			  No

Can we contact you by email?
  Yes 			  No

Information about you

Who is your next of kin?
Name:  ……..………………..Tel:…………………….
Relationship:………………………………….
Address:

Do you require an interpreter?
  Yes 			  No

What is your main language………………………….

Do you have any communication needs?
  Yes 			  No

If yes, what are these needs?

  Braille	  Audio	  Other (please state)
  BSL             Large Print 

Which of the following best describes how you think of yourself?

A: White
 British
 Irish
 Any other White background (Please Write in)

B: Mixed
 White and Black Caribbean
 White and Black African
 White and Asian
 Any Other mixed background (Please write in)

C: Asian or Asian British
 Indian
 Pakistani
 Bangladeshi
 Any other Asian background (Please write in)

D: Black or Black British
 Caribbean
 African
 Any other Black background (Please write in)

E: Chinese or other Ethnic Group
 Chinese
 Any other (Please write in)

 Not stated	

Which of the following best describes how you think of yourself?

  Woman (including trans woman)
  Man (including trans man)
  Non-binary
  In another way (please state)	

Is your gender identity the same as you were given at birth?

  Yes 	  No

Which of the following best describes how you think of yourself?

  Lesbian                         Bisexual            
  Gay                               Heterosexual/Straight
  In another way (please state)

What is your employment status? 
Please tick all options that apply

  Employed (full time)
  Employed (part time)
  Veteran (or ex-Veteran)
  Student (full time)
  Student (part time)
  Unemployed
  Retired

Are you are carer?    
(A carer is someone who provides unpaid care for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support)

  Yes			  No

If yes, who do you care for?
…………………………………………………………...

Online Services

Would you like to do any/both of the following?

  Book & Cancel Appointments online
  Order Repeat Medication online

Have you registered for Electronic Prescription Services (EPS)?

  Yes			  No

If yes which pharmacy have you nominated?

…………………………………………………………...

Please remember that you may need to update your nominated pharmacy if you are moving into the area.  This can be done by visiting your pharmacy of choice.

Medication , Family History & Lifestyle

Do you take regular repeat medication? 
  Yes			  No	

If yes please attach a printout of your repeat medication from your previous GP Practice

Are you allergic to any medication?
  Yes			  No	

Please state…………………………………………….
Have you ever suffered from?  (tick as appropriate)

  Epilepsy             High Blood Pressure  
  Cancer               Heart attack/Stroke  
  Asthma              Eczema/Hay fever   
  COPD                Diabetes  
  Depression        Blindness/Glaucoma  
  Other ………………………………………………
………………………………………………………….

Do you have a family history of any of the following?  If yes please detail family member(s) age and relation to you:

  Diabetes ……………………………………………
           
  Epilepsy…………………………………………….

  Stroke……………………………………………….

  Asthma……………………………………………...                    
   
  Breast Cancer……………………………………...                    

Have you had any significant operations? 

  Yes 			  No

Please give details:

Are you living with HIV?

  Yes 			  No
  I don’t know/unsure

Date of last cervical smear:

Do you enjoy? 

 Heavy Exercise           Light Exercise

 Moderate Exercise      Exercise is impossible

What is your smoking status?

  Current smoker            Ex-smoker
      
How many per day ………….

  Never smoked

This is one unit of alcohol… 

…and each of these is more than one unit

How many units of alcohol do you consume in a week?..............

AUDIT – C 

Questions	Scoring system	Your score	
	0	1	2	3	4		
How often do you have a drink containing alcohol?	Never	Monthly
or less	2 - 4 times per month	2 - 3 times per week	4+ times per week		
How many units of alcohol do you drink on a typical day when you are drinking?	1 -2	3 - 4	5 - 6	7 - 9	10+		
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		

SCORE

Scoring:
A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.

If your score is 5 or over please complete 
the next section	

SCORE

Score from AUDIT- C (other side) 

	

Remaining AUDIT questions

Questions	Scoring system	Your score	
	0	1	2	3	4		
How often during the last year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		
How often during the last year have you failed to do what was normally expected from you because of your drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		
How often during the last year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		
Have you or somebody else been injured as a result of your drinking?	No		Yes, but not in the last year		Yes, during the 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, during the last year		

TOTAL =  = 

Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,
 16 – 19 Higher risk, 20+ Possible dependence

TOTAL Score equals  
AUDIT C Score (above) +