Dr Rashid Ali Surgery @ Guttridge Medical Centre, Deepdale Road, Preston, PR1 6LL 
New Patient Registration form 2019

Title                				 Surname  				First Names  
                  
Date of Birth    
		
Home Address

Postcode:

Tel No:				             Email:							

Ethnic Group*
   White British  		Irish 				
   Black Caribbean 		African 		Mixed 				
   Asian Indian             	Pakistani 	 	Chinese 				      

Have you ever suffered from? (Tick as appropriate)* 

Epilepsy 		Yes / No 	Blindness/Glaucoma 	Yes / No 
High Blood Pressure 	Yes / No 	Diabetes 		Yes / No 
Heart Attack/Stroke 	Yes / No 	Depression 		Yes / No 
Cancer 		Yes / No 	Asthma 		Yes / No 
Eczema/Hay Fever 	Yes / No 	COPD 			Yes / No 

Carers* 
Do you have a carer? (If yes please give details) Yes / No
Carer Detail: 
Telephone: 
       
Are you a carer? (If yes please give details) Yes / No 
Are you a veteran? (If yes please give details) Yes / No 
    
Height					Weight

Do you smoke?  Yes / No 			If 'No', have you ever smoked?  Yes / No 
     
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? 
       
Would you like advice on giving up smoking?  Yes / No 

Alcohol Consumption
    
Signature:

Date: