Cofrestrwch gyda Phractis - Sketty and Killay Surgeries

Cais i Gofrestru'n Barhaol gyda Phractis Meddygol Cyffredinol

Rhaid llenwi'r ffurflen hon mor llawn â phosibl.

1. Manylion Personol

Teitl

Dyddiad geni

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

Rhif y GIG

Rydych chi:

Gwryw

Benyw

Cyfenw

Enwau Rhai

Adnabyddir fel

Cyfenw blaenorol

Enw cyn priodi mam

Tref a gwlad eich geni

Cyfeiriad

Cod post

Rhif ffôn

2. Gwybodaeth i'n helpu i olrhain eich cofnodion iechyd meddygon teulu blaenorol

Eich cyfeiriad blaenorol yn y DU, pan oeddech wedi’ch cofrestru gyda meddygfa meddyg teulu

Cod post

Enw’ch meddyg blaenorol pan oeddech yn y cyfeiriad hwnnw

Cyfeiriad eich meddyg blaenorol

3. Os ydych o dramor

Eich cyfeiriad cyntaf yn y DU lle roeddech wedi cofrestru gyda meddyg teulu

Os oedd yn byw yn y DU o'r blaen, dyddiad gadael

Dyddiad y daethoch i fyw yn y DU gyntaf

Ydych chi erioed wedi cofrestru â Meddyg Teulu y GIG yn y DU?

Ydw

4. Os ydych wedi gwasanaethu yn Lluoedd Arfog EM

Ydych chi erioed wedi gwasanaethu fel aelod o luoedd arfog ei mawrhydi?

Ydw

Dyddiad ymrestru

Dyddiad gadael

Cyfeiriad cyn ymrestru

Rhif gwasanaeth neu bersonél, Rhif BFPO

5. Sieciau

Os oes angen i’ch meddyg weinyddu meddyginiaeth a theclynnau meddygol (nid oes awdurdod gan bob meddyg i weinyddu meddyginiaeth)

Rwy’n byw mwy na milltir mewn llinell syth oddi wrth y fferyllydd agosaf

Byddai’n anodd dros ben i mi gael gafael arnynt gan fferyllydd

Eithrio o Gofnod lechyd Unigol y GIG

Rwy’n dymuno eithrio o’r Cofnod lechyd Unigol ac atal staff meddygol sy’n darparu gofal brys rhag gweld fy ngwybodaeth feddygol allweddol. Rwyf wedi derbyn digon o wybodaeth i wneud dewis gwybodus ac rwy’n cydnabod y gallai eithrio fel hyn amharu ar fy ngofal iechyd.
Mae rhagor o wybodaeth ar gael yn www.wales.nhs.uk/cofnodiechydunigol neu drwy ffonio Galw lechyd Cymru ar 0845 46 47

Gohebiaeth

Ticiwch y blwch yma os hoffech chi dderbyn gohebiaeth oddi wrthym yn y Gymraeg

6. Llofnod

Os oes angen i chi glirio'ch llofnod o'r blwch uchod a'i gychwyn eto, cliciwch yma.

Eich Llofnod

Y llofnod uchod yw:

Llofnod y claf ei hun
Ar ran y claf

Health Questionnaire

All information supplied will be recorded in your confidential medical records.

Practice handbook

You can download our practice handbook for more information about the services we provide, how the practice operates, and useful guidance for patients.

Download the practice handbook (PDF)

Contact Details

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?

Ydw

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?

Ydw

Smoking

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?

Alcohol

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 tell us your most recent measurements for the following (if known).

Height

Weight

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

Next of Kin

Name

Relation

Contact number

Family History

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?

Ydw

Which family member has or had this condition?

Stroke?

Ydw

Which family member has or had this condition?

Cancer?

Ydw

Which family member has or had this condition?

Medication

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

Ydw

Name of drug - Dosage

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

Allergies

Do you have any allergies?

Ydw

If Yes, please give details

Past Medical History

Please give details of any treatments/medical conditions.

Carer Information

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

Ydw

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

Ydw

Do you care for anyone else?

Ydw

History

Have you been registered here previously?

Ydw

Have you moved to the UK from abroad?

Ydw

Have you had a blood transfusion before 1996?

Ydw

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

Special Circumstances

Military Veteran

Have you ever served in the Armed Forces?

Ydw

Communication

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?

What is your ethnicity?

We now need you to verify your identity and your address

Please upload a copy of your passport or drivers licence

Please upload a document (dated within the last there months) identifying our home address

Vaccination History (Under 18s Only) - (Mandatory for all patients under 18 years of age)

Please provide details of all vaccinations the patient has received.

Significant Health Problems

For example: | Condition / Diagnosis | Date (approximate if unsure) | Ongoing? (Yes/No) |

Please list any significant past or ongoing health problems.

Female Patients Only – Screening History

If applicable, please provide details of your most recent screening tests:

Cervical smear test (last date):

Breast screening / examination (last date):