NEW PATIENT QUESTIONNAIRE

DR. P. R. JONES DR. B. McPHERSON

MB, ChB MB, ChB

The Surgery, North Back Lane, Stillington, York, YO61 1LL

Tel: 01347 810332 Fax: 01347 811190

Welcome to our surgery. As part of our service to all new patients we offer a “quick” health check, with one of the Doctors. This not only gives you the chance to discuss any health problems you may be having, but also enables us to gather some information on your past and present health. This is important to us, as there is often a delay before we are in receipt of your medical notes from your previous doctor.

We would be grateful therefore if you could spare a few minutes to complete this questionnaire and hand it to the receptionist as you make the appointment for your check up.

Full Name…………………………………………..Date of Birth……………………………

Telephone – Home…………………………………Work…………………………………….

Occupation………………………………………….Who lives with you…………………….

Illnesses which run in your family…………………………………………………………….

Has either Parent/Brother/Sister has Angina/Heart Attack/Stroke before the age of 60?

Please give details………………………………………………………………………………

Are you a carer?……………………………………………………………………….……….

Past illnesses and operations…………………………………………………………………..

Any allergies…………………………………………..Immunisations………………………

SMOKING- Do you smoke…Yes/No. If yes how many per day?......

If an ex-smoker when did you stop?......

ALCOHOL -What is your average daily or weekly intake?………………………………..

DIET-Any special features?…………………………………………………………………...

EXERCISE-How much do you take?………………………………………………………...

DRUGS-Please give details of any medication you take……………………………………..

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

CURRENT HEALTH………………………………………………………………………….

LADIES- Date of last Breast Screening………………………………………………………

Date of last smear and by whom………………………………………………………………

Today’s Date ………………………………………………………………

ETHNIC MONITORING QUESTIONNAIRE AND MAIN LANGUAGE SPOKEN

Due to new Department of Health guidelines we are required to request the ethnicity of our new patients.

Please tick which ethnic group you feel you belong to:

White

  British

  Irish

  Any other white background

Mixed

  White & Black Caribbean

  White & Black African

  White & Asian

  Any other mixed background

Asian or British Asian

  Indian

  Pakistani

  Bangladeshi

  Any other Asian background

Black or Black British

  Caribbean

  African

  Any other black background

Any other ethnic group

  Chinese

  Any other, please describe

  Do not wish to state

Language

Please state your main spoken language………………………………………………..