UPTON MEDICAL PARTNERSHIP

NEW PATIENT QUESTIONNAIRE

Name:Date of Birth:

Address:Ethnicity:

Place of birth:

Post code:If outside the UK, date of entry to UK:

If you have been outside of the UK for a period of 6

Telephone Number:months or more in the last 5 years please state:

Country visited:Dates:

Mobile Number:

Do you Smoke: YES/NO If yes how many per day?

If No have you ever smoked: YES/NO

Next of kin:

Relationship to you:Current smokers are advised to stop, please ask

Contact number:reception if you would like a leaflet

Weight:Are you allergic to anythingYES/NO

Height:If yes, what?

In the event of an emergency do you consent for NHS hospitals to access your medical

records so they may obtain vital information to help with emergency treatment YES / NO

Date of any vaccinations in the last five years:

Are you a Carer?YES/ NOIf yes, who do you care for:

On Average how many units of alcohol do you drink a week:

For the following questions please circle the answer that best applies to you:

1 unit = ½ pint beer or 1 small glass of wine or 1 single measure of spirits

1.How often do you have a drink that contains alcohol?

NeverMonthly2-4 times2-3 times4+ times

Or lessa montha weeka week

  1. How many standard alcoholic drinks do you have on a typical day when you are drinking?

1-23-45-67-910+

  1. How often do you have 6 or more units if female, 8 or more if male, on a single occasion in the last year?

NeverLess thatMonthlyWeeklyDaily or

Monthlyalmost daily

Has anybody in your family ever suffered from any of these illnesses?

What relationship to you?How old were they when first diagnosed?

Heart AttackYES/NO

AnginaYES/NO

StrokeYES/NO

DiabetesYES/NO

High blood pressureYES/NO

CancerYES/NOIf yes please give details:

Are you on a special dietYES/NOIf yes please give details:

Women Only:

Have you ever had a Cervical smear TestYES/NO

When was your last smear test:

What was the result of your last smear test:

Are you on any form of contraception: YES/NOIf yes please give details:

Do you or have you suffered from any of the following:

Date first diagnosed

Heart DiseaseYES/NO

High Blood pressureYES/NO

StrokeYES/NO

DiabetesYES/NO

EpilepsyYES/NO

AsthmaYES/NO

Chronic Obstructive Pulmonary DiseaseYES/NO

CancerYES/NOIf yes please give details:

Are you on any regular medication:

Are you undergoing or waiting for any medical treatment: