Cláraigh le Dochtúir Teaghlaigh

Teideal

Dáta breithe

When you register, it's essential to include your NHS number so that we can register you. You can use the NHS website to find your NHS number

Uimhir NHS

Tá tú:

Fireann

Mná

Sloinne

Réamhainmneacha

Ainm aitheanta

Sloinne roimhe seo

Ainm réamhphósta na máthar

Baile agus tír bhreithe

Seoladh

Cód Poist

Uimhir teileafón

Do sheoladh roimhe seo sa RA, agus tú cláraithe le lialann DG

Cód Poist

Ainm an dochtúra roimhe seo agus é ag an seoladh sin

Seoladh an dochtúra roimhe seo

Do chéad seoladh RA nuair a chláraigh tú le dochtúir teaghlaigh

Má bhí cónaí ort roimhe seo sa RA, dáta fágála

An dáta a tháinig tú chun cónaithe sa RA ar dtús

Ar chláraigh tú riamh le Dochtúir Teaghlaigh SNS sa RA?

Sea

Níl

Ar sheirbheáil tú riamh i bhFórsaí Armtha HM?

Sea

Níl

Dáta liostála

Dáta fágála

Seoladh roimh liostáil

Uimhir Seirbhíse nó Pearsanra, Uimhir BFPO

If you need your doctor to dispense medicines and appliances (note: not all doctors are authorised to dispense medicines)

Tá cónaí orm níos mó ná míle i líne dhíreach ón gceimiceoir is gaire

Bheadh deacracht mhór agam iad a fháil ó cheimiceoir

Diúltaigh Taifead Sláinte Aonair SNS

Ba mhaith liom tarraingt siar as an Taifead Sláinte Aonair agus cosc a chur ar fhoireann leighis cúram éigeandála a bheith in ann rochtain a fháil ar m’eochairfhaisnéis leighis. Tá go leor eolais faighte agam chun cinneadh eolasach a dhéanamh agus admhaím go bhféadfadh tarraingt siar a bheith díobhálach do mo chúram sláinte.
Tá tuilleadh faisnéise ar fáil ach cuairt a thabhairt ar www.wales.nhs.uk/individualhealthrecord nó trí ghlaoch a chur ar NHS Direct ar 0845 46 47

Comhfhreagras

Cuir tic sa bhosca seo le do thoil más mian leat comhfhreagras a fháil uainn i mBreatnais

Más gá duit do shíniú a ghlanadh ón mbosca thuas agus é a thosú arís, cliceáil anseo.

Do Shíniú

Is é an síniú thuas:

Síniú an othair féin
Thar ceann an othair

Full Name

Date of Birth

Email address

Gender

Marital status

Home phone number

Work phone number

Mobile number (if aged 16 or over)

Language preference

English
Welsh
Other

If Other, please specify

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccinations reminders and anything else relevant to your healthcare?

Sea

Níl

We have an electronic method of contact available for patients to contact the surgery for non urgent requests - do you consent for us to correspond with you via this method and supply us with a preferred email address for this purpose?

Sea

Níl

Do you smoke?

Yes
No
Ex-smoker

If yes, how many (Cigarettes per day, ounces of tobacco per day, Electronic cigarettes)

If ex-smoker, what date did you stop smoking?

For the following questions please answer to the best of your knowledge.

We have provided a basic guide to alcohol content below to assist your completion.

A 750ml bottle of wine contains 10 units.

A standard(175ml) glass of wine contains 2 units.

A single small shot of spirits (25ml) contains 1 unit.

A standard 70cl bottle of spirits contains 28 units.

A pint of 3.6% strength lager/beer/cider contains 2 units.

A pint of 5.2% strength lager/beer/cider contains 3 units.

How many units of alcohol do you drink a week?

Height

Weight

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

Name

Relation

Contact number

The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?

Heart Disease?

Sea

Níl

Stroke?

Sea

Níl

Cancer?

Sea

Níl

Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.

Sea

Níl

Name of drug - Dosage

Please add a photo of your most recent repeat medication slip if you have one.

Do you have any allergies?

Sea

Níl

If Yes, please give details

Please give details of any treatments/medical conditions.

Do you need / have anyone who looks after you or your daily needs as a Carer?

Sea

Níl

If Yes, would you like them to deal with your health affairs here?

Sea

Níl

Do you care for anyone else?

Sea

Níl

Have you been registered here previously?

Sea

Níl

Have you moved to the UK from abroad?

Sea

Níl

Have you had a blood transfusion before 1996?

Sea

Níl

If the answer is yes, have you had a Hepatitis C Blood Test?

Please tick any/all that apply.

Have you ever served in the Armed Forces?

Sea

Níl

Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?

Please note: This information helps us ensure everyone receives fair and appropriate care. It is entirely optional and will not affect your registration.

Yes I would like to provide my ethnicity
No I do not wish to provide my ethnicity

If you selected "Yes", please complete the section below to indicate your ethnicity

Asian - Asian Welsh or Asian British,

Black, Black Welsh, Black British, Caribbean or African

Caribbean
African
Any other Black -Black British - or Caribbean background

Mixed or multiple ethnic groups

White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or multiple ethnic background

White

Welsh English Scottish Northern Irish or British
Irish
Gypsy or Irish Traveller
Any other White background

Other ethnic group

Arab
Any other ethnic group

Cwmtawe Medical Group

Cwmtawe Medical Group

Iarratas chun Clárú go Buan le Cleachtas Leighis Ginearálta

1. Sonraí Pearsanta

2. Faisnéis chun cabhrú linn do thaifid sláinte Dochtúirí Teaghlaigh roimhe seo a rianú

3. Más ó thar lear tú

4. Má tá tú tar éis fónamh i bhFórsaí Armtha HM

5. Seiceálacha

6. Síniú

New Patient Registration Questionnaire

Contact Details

Smoking

Alcohol

Height & Weight - Please tell us your most recent measurements for the following (if known).

Next of Kin

Family History

Medication

Allergies

Past Medical History

Carer Information

History

Special Circumstances

Military Veteran

Communication

Do you wish to declare your ethnicity? (Required)