Date published: 12.10.2016

Please complete this questionnaire as fully as possible.

The information will help the doctor to make an initial assessment of your health, which may help in your future treatment.

Name ______Date of Birth ______

Weight ______Height ______

Blood pressure checked in the last 10 years? Yes / No

Tetanus vaccination in the last 10 years? Yes / No

Cholesterol checked in the last 2 years? Yes / No

SMOKING / EX-SMOKERS / PASSIVE SMOKING

Do you smoke? Yes / No If Yes, how many cigarettes per day? ______

If you smoke, how old were you when you started?

If you used to smoke, how old were you when you stopped?

If you used to smoke, how many cigarettes did you smoke per day?

Are you exposed to smoke at home? Yes / No

DIET

Do you have a varied diet including milk, meat, vegetables and fruit? Yes / No

If no, are you a vegetarian, vegan or other (please specify)

(Please circle)

EXERCISE

For how many minutes do you exercise at a time? How many times per week?

What type of exercise do you do? (walking, gym, gardening, dancing, cycling)

REPEAT MEDICATION

Please list your current repeat medications as prescribed by your previous Doctor.

Name of Drug / Strength / Dosage

If you are on repeat medications you will need to make an appointment with your new doctor before requesting your medication.

ALLERGIES

Please give details of any known allergies.

Non – Drug Allergies (bee stings, eggs)

Adverse drug reactions (Penicillin)

FAMILY HISTORY

Is there any of the following in your family (father, mother, brother, sister) before age of 65?

Heart Disease (Heart attacks, angina) Yes / No Which family member?

Stroke? Yes / No Which family member?

Cancer? Yes / No Which family member?

Site of cancer?

CARERS

Do you have anyone who looks after you or your daily needs as Carer? Yes / No

If Yes, would you like them to deal with your health affairs here? Yes / No

(our receptionists can help with these arrangements)

Do you care for anyone else? Yes / No

PAST AND PRESENT MEDICAL HISTORY

Significant on-going medical problems/conditions

Significant past medical problems/conditions

Any other information that you feel your new GP should know

PATIENT ETHNIC ORIGIN

Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.

Choose ONE section from A to E, and then tick ONE box to indicate your background.

A White

British
Irish
Any other white background please write below

B Mixed

White and Black Caribbean
White and Black African
White and Asian
Any other mixed background please write below

C Asian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background please write below

D Black or Black British

Caribbean
African
White and Asian
Any other black background please write below

E Chinese or other ethnic group

Chinese
Any other please write below

ALCOHOL

Please complete the following 4 questions

Fast Alcohol Screening Test (FAST)

Question / Score / Your Score
Score questions 1-3 / 0 / 1 / 2 / 3 / 4
1. How often do you have
8 units (msn)/6 units (women) or more drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
If you answered the first question “Never” – please stop now
2. How often, in the last year, have you not been able to remember what happened when drinking the night before? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
3. How often, in the last year, have you failed to do what was expected of you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Score question 4 / 0 / 2 / 4
4. Has a relative/friend/doctor/ health worker been concerned about your drinking or advised you to cut down? / Never / Yes, on one occasion / Yes, on more than one occasion
Total /

Score = 0-2 indicates SENSIBLE DRINKING or NO DRINKING

Score = 3 or more indicates HAZARDOUS or HARMFUL DRINKING

NEXT OF KIN

Name

DOB

Relationship to you

Contact telephone number

PATIENT DETAILS

Occupation

Marital Status

PATIENT CONTACT DETAILS

Home telephone number

Do you consent to us leaving messages on you home answerphone? Yes / No

Mobile telephone number

Do you consent to us sending you appointment reminders via text message Yes / No

ON-LINE SERVICE FACILITY

If you wish to have the facility to

Order Prescriptions

Make / Cancel Appointments Yes / No

IF YES, complete additional form which is enclosed in the New Patient Questionnaire Pack.

Patient Signature

Print Name

Date

Please hand your completed questionnaire in at reception. Thank you for completing this questionnaire.

Date received by the Surgery / Well person template
entered.
(inc Smoking, Height and Weight) / Ethnic origins entered / ALCOHOL – FAST SCREENING TEST entered via numerics screen
(Read code XaMwa + numeric value) / Next of kin entered on groups and relationships / Mobile entered, consent for contact entered
XaQid – consent
XaQmZ - decline / Home telephone entered.
If Pt consents to leave messages on answerphone then create a reminder
“Patient has given written consent for the surgery to leave messages on their home answerphone – see NPQ)
Signed / Dated

** Reception - please also tick - consent OR dissent in - record contact details (under administrative in address history) **

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