Silverdale Practice - New Patient Questionnaire

To help the practice provide your medical care, please give us some information, which will be part of your confidential health records, only used for your health care and only seen by doctors and their staff.

Contact details

The surgery may use these details to contact you about administration or healthcare matters, such as test results, prescriptions, clinic invitations reminders. Please update us if any of this information changes.

Title: Mr/Mrs/Miss/Ms/Dr/Other (please specify) Male/Female

Surname: Forenames:

Marital Status: S / M / Sep /Div / W Date of Birth: / /

Address …………………………………………………………………………………………………………………..

Phone numbers: Home: ………..…..…… Mobile: ……….………..……………. Work ………………………... Can we contact you by text? Yes / No Occupation: ……………………………………

Ethnic Origin

It would be very helpful to have this information because some medical conditions are much more common, and some medication can be less effective, in particular ethnic groups.

I would describe my ethnic origin as follows (Choose ONE section, then ü the appropriate box):
White
 British
 Irish
 Other White background / Mixed
 White and Asian
 White and Black African
 White and Black Caribbean
 Other mixed background / Asian or Asian British
 Bangladeshi
 Indian
 Pakistan
 Any other Asian background / Black or Black British
 African
 Caribbean
 Any other Black background
 Chinese /  Any other ethnic group /  I do not wish to disclose my ethnic origin
My main spoken language is:

Health information Height: Weight:

I have Never smoked  I am an Ex-smoker Date stopped smoking …………

I Smoke: Cigarettes per day Cigars per day

Roll your own oz/week Pipe oz/week

I am aware that the practice offers a smoking cessation service but I do not wish to take part at this current time: ………………………………… (Signature required if opting out of this service)

Alcohol: / Please tick the relevant answer
1.  How often do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4+ times per week
2.  How many standard alcoholic drinks do you have on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-9 / 10+
3.  How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Carers – Carers look after family, partners or friends in need of help because they are ill, frail or have a disability. If the person you care for is registered with this practice, please tell us their:

Name: Date of Birth: / /

Please provide details of your next of kin or carer:

Name: …………………………………… Your next of kin or carer address is:………………………………………………………………….

Telephone number………………………… ………………………….……………………………………......

If you are on any regular medication, you will need to see the doctor for a review to obtain your first repeat prescription.

Signed…………………………………….. Date ……………………………………………..