0113 261 4228
What's your title?
What's your first name?
What's your last name?
What's your date of birth?
What's your gender?
What's your address?
What's your postcode?
What's your phone number?
What's your email address?
Who is your GP?
Are you taking any medication (tablets, medicines or drugs)? If yes, please list:
Have you any allergies to medicines ie penicillin, substances or materials (latex/rubber)?
Do you have or have you had any of the following?
Congenital heart lesion/ cardiac pacemaker
Heart attack/ angina/stroke
High blood pressure
Low blood pressure
Asthma or hay fever
Hiatus hernia/ stomach trouble
Jaundice, hepatitis, liver disease
Diabetes – low blood sugar
Bone or joint disease
Please answer the following:
Are you pregnant or is it possible you may be pregnant?
Are you taking contraceptive pill? Certain medication may compromise its effectiveness.
Are you taking or have you taken steroids in the last two years?
Have you ever had a prolonged illness or been hospitalised?
Have you had any major/serious operations or radiation therapy?
Do you have or have you had any contact with Hepatitis or HIV/AIDS carriers which is likely to put you at risk from either of these viruses?
Did you as a child or since have brain surgery, growth hormone treatment before the mid-1980s or have a close relative with CJD?
Have you ever had any ill effects following dental treatment?
Have you or any relation had any severe prolonged bleeding problems?
Have you had any ill effects from local anaesthetic?
Have you ever had any ill effects from aspirin?
Do you smoke / previously smoked any tobacco products or chew tobacco, pan/betel nut or other similar products?
Do you drink alcohol?
Is there any other information about your medical history which may be important?
I understand and agree to The Parade Patient Agreement which all registered patients of the practice are subject to.
View the full agreement here.