Longton Grove Surgery
New Patient Questionnaire
Please complete this questionnaire as fully as possible at the time of registration and hand back to the receptionist. The information will help the nurses and doctors to make an initial assessment of your health which will help in your future treatment.
Title:………...... Surname: ………………………………… Forenames:……………………………………
Address:……….……………………………………Date of Birth:….……………………………….
……….……………………………………Home phone:.………………………………….
……….……………………………………Mobile phone:….....…………………………..
Email Address: …………………………………………………………………………………………………………………….
Do you consider yourself to have any communication needs e.g. deaf, blind, language?
If yes, please state your need: …………………………………………………………………………..
Next of Kin Details:
Name: ………………………………………………Phone: ………………………………………………………
Relationship to you: ……………………………………………………………(e.g. partner/parent/etc)
Have you ever served with the Armed Forces? Yes No PERSONAL DETAILS
How much do you weigh? …………… kg / What is your height? …………… cm
What is your Ethnic Origin?
White British / Sri Lankan
White Irish / Black African
Other White / Black Caribbean
Mixed Race:White & Black Caribbean / Other Black
White & Black African / Other Asian
White & Asian / Other European
Indian / Other Mixed Race
Pakistani / Other Ethnic Category
Bangladeshi / I would prefer not to state my ethnicity
What is your first spoken language?
Do you have someone who looks after you or your daily needs? Yes No
If yes, would you like them to deal with your health affairs here?Yes No
If yes, please speak to the receptionist who can help with these arrangements.
Do you care for anyone else?Yes No
If yes, ask the receptionist about Carers Support.
FAMILY HISTORY
Do you have any family history of heart disease?Yes No If yes, which family member was affected?………………………………
If yes, was the family member less than 60 or 60+?………………………………
Do you have any family history of: StrokesYes No
Diabetes Yes No
AsthmaYes No
MEDICAL HISTORY
Do you have any significant medical history that we should know about (including operations) – please give dates where possible; Yes No
………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………….
Are you on any regular medication?Yes No
If yes, please provide us with a list of your medication ……………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
*Please note you will need to see a doctor before any medication can be reissued.
Do you have any allergies, generally and to particular medication?Yes No
If yes, please give us the details …………………………………………………………………………………
……………………………………………………………………………………………………………………………………….
WOMEN’SHEALTH
Do you know when your last cervical smear was taken?Yes No
Date: ………………… Location: GP Surgery Result:Normal
HospitalAbnormal
Have you ever been invited for Breast Screening?Yes No
Date: ………………… Result:Normal Abnormal
Have you had a hysterectomy? Yes No
If yes, what type of hysterectomy was it?Partial Total
LIFESTYLE
What is your smoking status? Current smoker Ex-smoker Never smoked
If you smoke, how many do you smoke a day? …………………..
How old were you when you started smoking?…………………..
Are you interested in seeing a nurse to stop smoking?Yes No
If you used to smoke, how old were you when you stopped?…………………..
If you used to smoke, how many did you smoke a day?…………………..
How would you classify your level of exercise?
Exercise physically impossibleEnjoys moderate exercise
Avoids exerciseEnjoys heavy exercise
Enjoys light exerciseCompetitive athlete
Have you ever drunk alcohol?Yes No
On average, how many units of alcohol do you drink each week?……………………
1 pint of beer/lager/cider / Alcopop / 175ml glass
of wine / Single measure
of spirits / Bottle of
Wine
2 units / 1 ½ units / 2 units / 1 unit / 9 units
Questions / Scoring System (Please circle)
0 / 1 / 2 / 3 / 4
How often do you have a drink thatcontains alcohol? / Never / Monthly
or less / 2-4
times a
month / 2-3
times a
week / 4 ormore
times a
week
How many standard alcoholic drinksdo you have on a typical day whenyou are drinking? / 1 -2 / 3 - 4 / 5 - 6 / 7 - 8 / 10+
How often do you have 6 or more standard drinks on one occasion? / Never / Less than
monthly / Monthly / Weekly / Daily or
almost daily
How often in the last year have you found that you were not able to stop drinking once you started? / Never / Less than
monthly / Monthly / Weekly / Daily or
almost daily
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
How often in the last year have you needed an alcoholic drink in the morning to get you going? / Never / Less than
monthly / Monthly / Weekly / Daily or
almost daily
How often in the last year have you had a feeling of guilt or regret after drinking? / Never / Less than
monthly / Monthly / Weekly / Daily or
almost daily
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
Have you or someone else been injured as a result of your drinking? / No / Yes, but not in the last year / Yes, during the last year
Has a relative/doctor/health worker been concerned about your drinking or advised you to cut down? / No / Yes, but not in the last year / Yes, during the last year
New Patient Questionnaire - April 2017