Kirkoswald Surgery

Kirkoswald

Penrith CumbriaCA10 1DQ

 01768 898560

New Patient Health Questionnaire - Adult

Thank you for joining Kirkoswald Surgery. It often takes several weeks for your records to reach us from your previous doctor. So, to ensure that we have up to date medical and personal details, please complete this registration form as fully as possible. If you have any problems completing any section please ask for assistance. You may attach a separate sheet if you wish to give us any further information. After completion the questionnaire should be returned to the receptionist.

The information you give us is confidential and is subject to the Data Protection Act.

Personal details:

Surname………………………….……………Forename/s:………………………………..………

Previous Surnames: (if any)………………………………………………………………………. M / F

Title:………………………………………Date of Birth:…………………………...………..……………

Address (inc postcode):……………………………………......

……………………………………………………………………………………………….………………

Telephone Number (and area code):Home:………………………………..………

Work:………………………………..…..…Mobile:………………………….……………

Religion:……………………………………

Please give place and country of birth…………………………………………………………………...

To which ethnic minority does you belong (please circle)

(White)White BritishIrish

(Mixed)White & Black CaribbeanWhite & Black AfricanWhite & Asian

(Asian)IndianPakistaniBangladeshi

(Black)CaribbeanAfrican

(Chinese)Chinese

Next of Kin:

Name:
Address:
Telephone Number:
(inc area code):
Relationship to you: / Home: Work:
Mobile:
Special circumstances:
(please tick if any of these apply to you) / I am a carer (non-professional) for…………………………………
I have a carer, please give name …………………………………..
I am registered disabled
I am house bound
I live in a nursing home
I live in a residential home

Health and Lifestyle:

Smoking Status
Please tick / Never smoked: Ex-smoker: - Date stopped………………….
Cigarette smoker:….. per day Cigar smoker:…….per day
Roll ups:………..oz./g per week Pipe:…….oz./g per week
Alcohol Use / A unit of alcohol is approximately 1/2pint standard (3.5%) / 1/3pt of premium (5%) beer / 125ml of wine / 25ml of spirits.
How many units of alcohol do you drink in a typical week? ………………………..
Alcohol Use Screening
(please circle your answer to each question) / 0 / 1 / 2 / 3 / 4 / Your score
How often do you have a drink containing alcohol? / Never / Monthly
or
less / 2 – 4 times per month / 2 – 3 times per week / 4+ times per week
How many units do you have on a typical day when you are drinking? / 1 - 2 / 3 - 4 / 5 - 6 / 7 - 8 / 10+
Men: how often do you have EIGHT or more drinks on one occasion?
Women: how often do you have SIX or more drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily
Add up your score: A total of 5+ indicates hazardous or harmful drinking.
Do you eat a varied / balance diet? / Yes / No / If not, please give details
Do you eat a particular diet? / Yes / No / If yes, please give details:
Vegan / Vegetarian / Low salt / Low fat / Gluten free / other please specify
Do you take regular exercise? (At least 30minutes x 3 per week) / Yes / No
Does anyone living in the household smoke? / Yes / No
Do you have any concerns about your memory? / Yes / No

Past Medical History:

Do you currently suffer from any medical problems / conditions / illnesses / diseases? / Date / Brief details
Have you had any significant medical problems / conditions / illnesses / diseases?
Details of hospital admissions / operations and dates
Immunisations
Please list (include Flu, pneumococcal)
Current prescribed medication
(please list giving dose and frequency, or attach the repeat part of their last prescription)
Allergies ( Medicines, food, animals, bites)
Please give date and result of last Cervical Smear (women only)
Please give date and result of last Mammogram (women only)
Please give date and result of last Bowel Screening test (men & women 60years and over)
Please give your current height……..……..cm weight…….……..kg

Family History:

Is there a first degree family history of? / Yes / No / First degree family members are mother / father / brother / sister / Age when first diagnosed
Heart Attack / Angina (onset before age 60)
Heart Attack / Angina (onset after age 60)
High blood pressure
CVA / Stroke
Diabetes
Asthma / COPD
Cancer
If yes , please give details of the type of cancer:
Severe Allergies
If yes , please give details:

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

For Office Use Only
  • Form checked and fully completed
  • GMS1 form received and checked
  • Practice Leaflet given
Date…………………………………… / Yes / No
Yes / No
Yes / No
Receptionist’s Signature:
…………………………………………….

Thank you very much for your help.

1

New adult patient questionnaire May 2014. LS