Llansamlet Surgery New Patient Registration Health Questionnaire

LLANSAMLET SURGERY NEW PATIENT REGISTRATION HEALTH QUESTIONNAIRE

PLEASE ENSURE YOU FILL IN THIS QUESTIONNAIRE BEFORE YOU ATTEND FOR YOUR REGISTRATION APPOINTMENT. IF YOU ATTEND WITHOUT THE QUESTIONNAIRE BEING FILLED IN THE NURSE WILL ASK YOU TO GO TO THE DESK TO BOOK ANOTHER APPOINTMENT.

Please answer the following questions as best you can. If you are unsure of the answer, leave blank and discuss it with the nurse when you attend for your new patient examination.

Mr / Mrs / Ms / Miss / Master ______(Surname)

First Name ______DOB ______/______/______

Previous Name (if applicable) ______

Address ______

Home Tel No ______Work/Mobile Tel No ______

E-mail Address: ______

Occupation ______

Previous Occupation if retired/unemployed ______

Marital Status: Single / Married / Divorced / Widow / Widower / Separated / Co. Habit.

Ethnic Origin: White / Black Caribbean / Black African / Black, other ethnic group / Indian / Pakistani / Bangladeshi / Chinese / Other Asian ethnic group / Vietnamese / Irish Traveller / Other –

Please state ______

Religion: (Please state) ______

Language: Main/first language ______Other languages______

ABOUT YOUR HEALTH:

Have YOU been diagnosed as having any of the following:

Stroke ______Date ______

Mini Stroke ______Date ______

(A mini stroke causes temporary problems which resolve within 24 hours)

Heart Attack ______Date______

Angina ______Date ______

High Blood Pressure ______Date ______

Asthma ______Date ______

Diabetes ______Date ______

Is blood sugar controlled by: Diet / Tablets / Insulin

Please list any other serious illnesses with dates:

______

Current Medication: ______

______

Disabilities:

Do you have any disability? YES / NO (Please delete as appropriate)

If yes, please give details: ______

______

Do you require any assistance with communication e.g. loop hearing or assistance from a British Sign Language Interpreter? YES/NO (Please delete as appropriate)

Have you ever served in the Armed Forces? YES/NO (if yes please give details)

Exercise: How would you describe your usual exercise level?

Inactive (no exercise at all)

Gentle (walk to shops, short walks)

Moderate (Long walks, bike rides)

Vigorous (play sport, run, gym)

Diet:

Think about your fat intake and whether you have fresh fruit and vegetables on a regular basis.

Fried foods such as chips, bacon, sausages etc and high fat/sugar snacks like crisps and chocolate make a poor diet.

Is your diet: Good / Moderate / Poor (Please delete as appropriate)

Do you have plenty of fibre? Yes / No (brown bread, fruit, high fibre cereals)

Is your diet mostly low in fat? Yes / No

Alcohol: Do you drink (ever!) Yes / No If yes, how many units per week? ______

(1 unit = half pint beer or lager, one small glass wine or one spirit measure)

Smoking: Do you smoke? Yes/No If yes, how many a day ______

If No, have you ever smoked in the past? If yes, when did you stop and how many did you smoke?

______

WOMEN ONLY

Have you had a cervical smear? Yes / No If yes, what date was the last test?

______

Have you had a mammogram or been to a breast clinic recently? Yes / No If yes, what date

______

Contraception: Do you use any? Yes / No If yes, please circle: Condoms / Pill / Injection / Coil / Cap / Implant

Please answer the following questions as best you can. If you are unsure of the answer, leave blank and discuss it with the nurse when you attend for your new patient examination.

CHILDREN AGED 6 TO 16 YEARS

Rubella ______/______/______BCG ______/_____/______

School Leavers Booster ______/______/______

ADULTS

Tetanus – Have you had a full 3 vaccination course? Yes / No If yes, what date/s

______

Any travel vaccinations? Please list them here (If you have had them from us, leave this section)

______Date ______/______/_____

FAMILY ILLNESSES (CLOSE FAMILY, please state who e.g. Mother / Father etc)

Stroke ______

High Blood Pressure ______

Diabetes ______

Asthma ______

Heart Attack/ Angina ______

1st Degree Relatives under 60 YES/NO (1st Degree Relatives = Parents, Grandparents

Or Siblings)

2nd Degree Relatives under 50 YES/NO (2nd Degree Relatives = Uncle, Aunt, Cousins)

IF YES [re Heart Attack/Angina] FOR LIPIDS BLOOD TEST = FASTING

TO BE COMPLETED BY THE PRACTICE NURSE ON THE DAY OF THE EXAMINATION

Blood pressure ______/______

Height ______Weight ______

Urine Sample Tested? Yes / No

If yes, Glucose ______Protein ______

FOR PATIENTS AGE 65 YEARS AND OVER ONLY:

Pulse Rate: ______Pulse Rhythm: ______

Tick for any health promotion advice given:

Smoking cessation Dietary Advice Weight Reduction

Alcohol Consumption Exercise Blood pressure

Is the patient a carer? Yes / No – If Yes, Please complete a Carers form if consent is given

Miscellaneous ______

______

Patients Previous Address: ______

______

Patients Previous GP (Incl address) ______

______

Patients Signature ______Date: ______

Practice Nurse Signature ______Date: ______

Entered on Computer By ______Date: ______

TO BE COMPLETED BY RECEPTION/ADMIN STAFF

Proof of address seen by ______

Updated IB 18-04-17