NEW PATIENT QUESTIONNAIRE:

Are you a carer? Yes [  ]  No [  ] If yes who do you care for?……………………………

Relationship:…………………………………………………………………………………..

Next of kin: …………………………………………… Tel. No:. ……………………………..

Relationship:………………………………………….

Home telephone number:
Mobile telephone number:
Email address:

Town of birth:

Country of birth:

Nationality:

Date of birth:

Age:

 Weight:

Current Address:                                                             Previous Address:

Post code:

 Height:

Gender:  Male [  ]     Female [  ]
Other [  ]      

Preferred Title:

Surname:

Forenames:

Marital Status:

Occupation:

Please complete this questionnaire, as it will help us to help you until your records arrive from your previous doctor

Do you have any allergies? Yes [  ]   No [  ] 

If yes, please list:                       Drugs: ………………………………………….
                                                              ………………………………………….
                                                 
                                                  Others: ………………………………………….
                                                              ………………………………………….

Please turn over

Are you on a special diet?        Yes [  ]   No [  ]
If yes please specify ……………………………………………………………..

Do you smoke?   Yes [  ]  / No [  ] :     Cigarettes [ ]  Cigars [ ]  Pipe [ ]
How many do you smoke each day? ……………………………………………
If you smoked in the past, when did you stop? …………………………………

Have you or a close blood relative under the age of 60 suffered from any of the following? If yes please state if self or which relative
Heart Attack: 	Yes / No ….………..    	 Cancer:   	Yes / No …………………
Diabetes:     	Yes / No ……………………..  High BP:  	Yes / No …………………
Stroke:      	Yes / No ……………………..  Tuberculosis:  Yes / No …………………
COPD:      	Yes / No …………………….. Thyroid problem: Yes / No ….................
Stroke 		Yes / No ……………………..

Please list any current medication or attach repeat slip:
Drug	Strength	Dose	

			

			

			

If you have regular, prescriptions please make a New Patient appointment for a review with a GP or Nurse, to enable us to organise repeat medication.

If you would like to attend a new patient health check please speak to Reception

Please give detail and date of any conditions, operations or serious illnesses you have had:

How many units of alcohol do you drink each week?............................. units
(1 unit = ½ pint beer = 1 single spirit = 1 glass of wine. If none put NIL)

How often do you have a                 Never    Monthly     2- 4times     2-3 times    4+ times
drink that contains alcohol?                           or less      per month    per week    per week 
How many standard alcoholic
drinks do you have on a typical         1-2        3-4         5-6        7-9        10+
day when you are drinking? 

How often do you have 6 or more     Never   Less than   Monthly     Weekly     Daily or almost
Standard drinks on one occasion                  monthly                                         daily

Do you or your carer have any communication/information needs relating to a disability, impairment or sensory loss and, if so, what are they?

Would you like a Summary Care Record?    Yes [  ]   No [  ]                                               
In event of emergency, it allows other health care providers access to any pre-existing conditions and medication
Would you like to receive text reminders for appointments? Yes [  ]      No [  ]
(This may include relevant Health Questionnaires from time to time.)
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Please ensure you have read and fully understand the information regarding these service

es. 

Ethnicity: 
Please specify the ethnic group you consider you belong to:
White British				[  ]
White Irish				[  ]
Black Caribbean			[  ]
Black African 				[  ]
Black Caribbean and White 		[  ]
Black African and White 		[  ]
Indian 					[  ]
Pakistani				[  ]
Bangladeshi 				[  ]
Other Ethnic group 			[  ]
I do not wish to say 			[  ]

Do you Speak English  Yes [  ]	No [  ]

Do you Read English	  Yes [  ]	No [  ]

First Language: