Mayfair Doctors Registration Form

Personal Details

Full Name *

Title First Name Last Name

Date of Birth *

Day Month Year

Gender *

Nationality

Address

Street Address

Street Address Line 2

City County / State

Postal / Zip Code Country

Phone Number *

E-mail *

If patient is child, then this section to be filled in with the details of parent or legal guardian.

Full Name

Title First Name Last Name

Address, if different from above

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

G.P. Details

Would you like us to contact your G.P.?

Yes No

G.P. Name and Address

Emergency Contact

Full Name

Relationship

Address

Phone Number

Carer

Do you have a carer?

Name

Would you like them to deal with your health affairs here?

Personal Medical History

Have you ever suffered or do you suffer from

chronic illnesses? *

Comments

heart or chest problems? *

Comments

blood pressure problems? *

Comments

epilepsy fits, faints or blackouts? *

Comments

heart disease / heart attack *

Comments

diabetes? *

Comments

a stroke? *

Comments

allergies, hay fever or eczema? *

Comments

cancer or been treated for cancer before? *

Comments

blindness or glaucoma? *

Comments

depression or psychosis? *

Comments

Do you have any disabilities? *

Comments

Have you had an operation or are there any other medical conditions the doctor should know about? *

Please list

Please specify all drugs, medicines, tablets or pills that you take regularly:

Are you allergic to any medication (e.g. penicillin)? *

Please list

Your Health

Do you smoke? *

How many cigarettes per day?

Are you an ex smoker? *

Date stopped:

Do you drink alcohol? *

How many units per day 1 unit = 1 glass of wine or 1 pint of beer or 1 measure of spirit

Family Medical History

Is there anyone in your family who has had:

Heart disease / heart attack Strokes Blood Pressure Diabetes Asthma Cancer Any chronic illness

Women only

Have you had a cervical smear test in the last three years?

Date and result:

Have you had a hysterectomy?

Date and result:

Do you take the contraceptive pill?

Which one:

Do you have a coil/IUD fitted?

When and what type:

Are you pregnant?

Any past pregnancies

Please list the years:

Any complications during pregnancies

Please list:

I have carefully read and understood this questionnaire and filled this form to the best of my knowledge.

I am aware that this is a private health clinic, and I will be charged a consultation fee, and any additional treatments or tests will incur further charges, which I will be made aware of before undertaking. If I am unsure about costs of my treatment, I will ask for clarification from a member of staff. I will pay the fees I have incurred prior to leaving the clinic. I understand there is no obligation to any treatment or tests after the initial consultation.

I agree with the above statement. *

How are you paying? *

Would you like us to contact you with any news or information which may be of interest to you? *