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Telephone lines open Mon - Fri: 8:30 - 18:00
Doors open Mon - Fri: 8:00 - 18:00

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Home
Practice
- Appointments
- Staff
Patients
Dermatology
Prescriptions
Travel Advice
News
Flu Vaccinations
Contact

Patient Questionnaire

In order to enable us to provide you with the best care possible, it is helpful to obtain some details about you and your lifestyle. Please take a few minutes to answer the following questions. All information will be kept in the strictest of confidence.

About your Residence Status

Have you previously been registered with Eyre Medical Practice?

Yes No

Were you born in the UK?

Yes No

If “No” please tell us the date you entered the UK

If previously resident in UK

Date of leaving UK

Date you returned to the UK

Your Details

Full Name

Sex

Male Female

Date of Birth

Place of Birth

Occupation

Marital Status

Email Address

Telephone Number

Are you permanently housebound?

Yes No

Keysafe Number

Mobile Number

Medical Problems

Have you had diagnosed – please tick and give date of diagnosis in the text field below (if known)

Angina Asthma Cancer COPD Diabetes (Insulin Depend) Diabetes (Non-Insulin Dep) Epilepsy Heart Attack Heart Disease Hypertension Hypothyroidism Stroke None of these

Please enter the condition and the date of diagnosis (if known)

Known Drug Allergies

Full Name of Drug

Reaction

Allergy Intolerance

Severity

Minimal Mild Moderate Severe Very Severe Potentially Fatal

Certainty

Tentative Unlikely Possible Likely Certain Absolute

Any Other Allergies?

Current Medication

If you are taking regular medications, please list them here

Preferred Pharmacy

Local pharmacies provide a prescription collection service from the practice. Please let us know which pharmacy you would prefer to collect your acute/ repeat prescriptions

Name of preferred pharmacy

Are you a Carer?

Do you provide help and support to a friend, neighbour or relative who could not manage otherwise because of frailty, illness, disability or a mental health problem?

Yes No

Health & Lifestyle Details

Alcohol (1 unit = 1/2 pint, or 1 pub measure of spirits, or 1 glass of wine)

Smoking

Never Smoked Ex-Smoker Current Smoker

Height

Weight

Which Ethnic Group do you belong to?

White Group

White Group – British White Group – Irish White Group – Other White Background

Mixed Group

White and Black Caribbean White and Black African White and Asian

Asian or Asian British Group

Indian or British Indian Pakistani or British Pakistani Bangladeshi or British Bangladeshi Other Asian Background

Black or Black British Group

Caribbean African Other Black background

Chinese or other ethnic group

Chinese Other Ethnic Group

Interpreter needed

Yes No

If yes, what language is required?

Do you provide help and support to a friend, neighbour or relative who could not manage otherwise because of frailty, illness, disability or a mental health problem? If the answer is YES, then please tick this box.

Yes

As part of your medical care may we share information with the Out of Hours, the local hospital and other emergency health services? This is known as Key Information Summary (KIS). Please write YES or NO to consent/dissent to us sharing your information.

Yes No

Name

Digital Signature

Next of Kin Name

Next of Kin Address

Next of Kin Telephone Number

Next of Kin Relationship to patient

Power of Attorney

Have you granted Power of Attorney?

Yes No

If Yes, who is your attorney?

Attorney Telephone Number

Blood Transfusion and Blood Products

If you have had a blood transfusion before 1991, or any blood products before 1986 or an organ transplant before 1992, please speak with a GP as you may benefit from testing for Blood Borne Viruses.

Eyre Medical Practice

31 Eyre Crescent
Edinburgh
EH3 5EU

T: 0131 556 8842
F: 0131 557 2177

Minor Injuries Clinic

Western General Hospital
Crewe Road South
Edinburgh
EH4 2XU

T: 0131 537 1330

Opening Hours

Doors open – 8.00am – 6.00pm
Telephone lines open – 8.30am – 6.00pm
Wednesday Lunchtime
Closure 12.30pm-1.30pm

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