YOUR CONTACT DETAILS

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Date of Birth Required
Address Required
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INFORMATION ABOUT YOU

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Do you need an interpreter? Required
Ethnic Group Required

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PREVIOUS GP

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PROOF OF IDENTITY AND ADDRESS PROVIDED

Identity Document Type Required
Have you ever suffered from? (tick as appropriate)
Are you registered disabled?
Are you allergic to any medicines? Required
Have you ever refused treatment/screening of any kind? Required
Have you ever suffered from? (tick as appropriate)
Do you have any other mental health issues?

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CARERS

Do you have a carer? Required
Are you a carer? Required

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WOMEN

Have you ever had a cervical smear? Required

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WILL

Do you hold a Living Will? Required

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SMOKING

Do you smoke? Required
If 'No', have you ever smoked? Required
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Would you like advice on giving up smoking?

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ALCOHOL

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FAMILY HISTORY

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NEXT OF KIN

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FOR PATIENTS AGED 65 AND OVER OR THOSE WITH A CHRONIC DISEASE (E.G. ASTHMA OR DIABETES)

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CONTACTING YOU

Do you agree that you may be contacted from time to time, via email and/or SMS, with p.ractice news, advice about my health and/or appointment reminders Required

SIGNITURE

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Date Required
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