Dr Rachel Tomalin & Dr Gareth Watson

NEW PATIENT HEALTH QUESTIONNAIRE

Dear Patient:

Whilst we are waiting for your medical records to reach us from your previous GP, it would be helpful to your new doctor to have some background information. It would be appreciated if you could complete this questionnaire, which will remain confidential. Should you have any difficulty answering any of the questions, please ask a member of staff for assistance.

Your Details:
Surname: …………………………….………… Forename(s): ……………………………….
Date of Birth: ……………………………….….. Title: ………….….……………………………
Address: ……………………………………………………………………………………………..
..……………………………………………...... Postcode: ……………………………….…...
Home telephone………………………….……. Mobile: ………………………………….……
Email address: …………………………………..……………………………………………......
Do you agree to us contacting you by email? Yes / No
What is your ethnicity?: …………………………………......
Your Next of Kin:
Name: …………………..…………………...... Relationship: ......
Address: ……………………………………………………………………………………………..
..……………………………………………...... Postcode: ……………………………….…...
Home telephone: .……………………….……. Mobile: ………………………………….……
CARERS
Do you have anyone who looks after you or your daily needs as ‘A Carer? Yes / No
If “Yes”, would you like them to deal with your health affairs here? Yes / No
(the receptionist can help with these arrangements)
Are you a ‘CARER’ for anyone else? Yes / No
Who are you a ‘CARER’ for? (family member, friend) ……………………..
If “Yes”, ask the receptionist about Carers support
ALLERGIES
Are you allergic to anything at all? Yes / No
If yes, please give details:
PERSONAL MEDICAL HISTORY
Please give details of treatment for any long term medical conditions i.e. Diabetes, Asthma, C.O.P.D, Blood Pressure, Mental Health:
SURGICAL HISTORY
Please give details and dates of any operations:
CURRENT MEDICATION
PLEASE ATTACH A COPY OF YOUR CURRENT REPEAT MEDICATION SLIP
FAMILY MEDICAL HISTORY
Has any of your IMMEDIATE family (i.e: parents or siblings) been diagnosed with any of the conditions listed below before the age of 65?
Diabetes Yes / No Which family member? …….……………..
Heart Disease (heart attacks, angina) Yes / No Which family member? ……………………
Stroke Yes / No Which family member? ……......
Cancer Yes / No Which family member? ……………………
High Blood Pressure Yes / No Which family member? ……………………
FEMALE PATIENTS
Are you currently using contraception? Yes / No
If so, what method ……….…………………………………………….
Do you have a Uterine Coil ? Yes / No Date of Insertion …………………
Do you have an Implant? Yes / No Date of Insertion ………………….
Date of last cervical smear: ……….………..… Result of most recent smear: ..………………
Please give details of any pregnancies: ……………………………………………………………
……………………………......
LIFESTYLE:
Weight (approx): ……………… Height: …………… Waist Measurement: …….………
SMOKING STATUS
Do you smoke? Yes / No
If Yes, how many:
Cigarettes per day ……... Cigars per day ….….. Ounces of tobacco per day …….
If you are a current smoker would you like to discuss with the nurse how the practice can help you ‘QUIT’?
Yes/No …… If ‘YES’ we will contact you to arrange an appointment with the nurse
EX-SMOKERS
When did you stop smoking? ………… How much did you smoke per day? ……………
PHYSICAL ACTIVITY QUESTIONNAIRE
1.  Please tell us the type of physical activity involved in your work: / Please mark one box only
a / I am not in employment (e.g. retired, retired for health reason, unemployed, full time carer etc )
b / I spend most of my time at work sitting (such as in an office)
c / I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (i.e. hairdresser, shop assistant, child minder)
d / My work involves definite physical effort including handling of heavy object or the use of tools (i.e. plumber, electrician, gardner)
e / My work involves vigorous physical activity including handling of very heavy objects (i.e. construction worker, refuse collector)
2. / During the last week how many hours did you spend on each of the following activities?
Please mark one box only on each row / None / Some but less than 1hour / 1 hour but less than 3 hours / 3 hours or more
a / Physical exercise such as swimming, aerobic, gym work out
b / Cycling, including cycling to work and during leisure time
c / Walking, including walking to work, shopping, for pleasure etc
d / Housework, childcare
e / Gardening, DIY
How would you describe your usual walking pace? / Please mark one box only
a / Slow pace
b / Steady average pace
c / Brisk pace
d / Fast pace
DIET
Do you add salt to your food after cooking? / YES/NO
Do you have a varied diet including milk, meat, vegetables and fruit? / YES/NO
Do you consider yourself to have a healthy diet? / YES/NO
ALCOHOL
Do you drink alcohol? Yes / No
If Yes,
How often do you drink more than 6 units (if you are a woman) or 8 units (if you are a man)?
Never Less than Monthly Monthly Weekly Daily or almost daily
This is one unit of alcohol…

…and each of these is more than one unit

Thank you for completing this questionnaire

~

PLEASE NOTE

IF ANY PART OF THE FORM IS NOT COMPLETED THIS MAY DELAY YOUR REGISTRATION.

THE REGISTRATION PROCESS TAKES A MINIMUM OF 2 WEEKS

We may contact you to invite you in for an up to date Blood Pressure Check and Blood Test if you are on regular medication

Dr Tomalin & Dr Watson

New Patient Health Questionnaire

Date Reviewed: September 2013

Review Date: September 2015 or earlier if required Page 1 of 5