NEW PATIENT QUESTIONNAIRE
To be completed by the person applying to register or their parent/guardian.
Please complete this form in BLOCK CAPITALS
Title: Mr/Mrs/Miss/Ms/Other (please state ) / NHS Number (if known):Surname: / First Name(s):
Date of Birth: / Occupation:
Address:
Postcode: / Email address:
Telephone numbers – Daytime: / Evening: / Mobile:
Can we communicate with you via / Text message? Yes/No / Email? Yes/No
Practice staff please read code “no” to SMS as EMISNQCO73 and “no” to email as EMISNQDEG33
First spoken Language:
(You can decline to answer)
Are you housebound? / Yes / No / Are you a Carer? / Yes / No
Do you have a Carer? If yes, please give a name and telephone number
Name, address and contact telephone number of Next of Kin: (Please state whether parent, son, daughter, etc).
Do you suffer from any of the following? Or does an immediate family member where indicated?
Conditions / You / Tick only if affected family member is a parent, son, daughter, brother or sisterYes / No / Yes / No
Asthma or COPD
Cancer
Diabetes
Thyroid problems
Stroke
Angina/Heart Attack
Blood Pressure
Kidney Problems
Have you received treatment for depression?
Any other medical history (please state below)
Alcohol Consumption – complete if aged 16 and over (Please see appendix 1 for definition of units)
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly
or less / 2 - 4 times a month / 2 - 3 times a week / 4+ times a week
How many units of alcohol do you drink on a typical day when you are drinking? / 1 -2 / 3 - 4 / 5 - 6 / 7 - 9 / 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
TOTAL
Smoking
QuestionsDo you smoke / Yes / No
If no, have you ever smoked / Yes / No
How many cigarettes or ounces of tobacco do you smoke per week
Would you like advice about giving up / Yes / No
If you are aged 16 and over, please weigh yourself and check your height and calculate your BMI (see appendix 1 for instructions).
Height: / Weight: / BMI:
Women’s Health
Are you pregnant? / Yes / No
Have you had a smear? / Yes / No / If yes, when and result?
Have you had a hysterectomy? / Yes / No / If yes, when?
Allergies
Do you have an allergic reaction / Yes / No / If yes, please specify
e.g. rash/collapse, to any
medication and/or eggs?
Please attach a printed list of repeat medication from your previous surgery or list below. State “NONE” if you are not on any repeated medication. Please use a separate sheet if necessary.
NAME of Medication (State in what form e.g. tablets, capsules, liquid/inhaler) / DOSE? i.e. 1 a day/2 puffs 4 times a day / What complaint is it taken for?
If you would like to book a new patient health check with a nurse or health care assistant, please contact us on 01737 360202. If you are between 40 and 74 you are eligible for a free NHS health check so please enquire at reception and book yours.
If patient is under 18 years of age please bring in your child’s immunisation record book.
Please tick this box if you wish your clinical information to be withheld from the Summary Care Record
What does it mean if I DO NOT have a Summary Care Record?
Summary Care Records allow immediate sharing of key patient data in primary and secondary care. NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you have any questions, or if you want to discuss your choices, please contact the practice manager.
Patient signature: ...... Print Name: ......
Date: ......
If signing on behalf of the patient please state what your relationship is to the patient.
(e.g. parent, carer, guardian, step-parent, etc.)
Relationship to patient: ......
For office use only
Date of “New Patient Appointment” ………………………………………………..
New Patient Questionnaire (Appendix 1)
UNITS OF ALCOHOL
1 unit / = / ½ pint of ordinary beer, lager (Carling/Fosters) or cider (4.0/4.5% of alcohol)1 small (125ml) glass of wine
1 single pub measure of spirits
1 large pub measure of fortified wine such as port or sherry
1.4 units / = / ½ pint premium beers and Grolsch/Budweiser/Kronenbourg 1664 (5%)
1.5 units / = / 1 Large glass of wine (average bottle of wine = 9 units or 6 glasses x 1.5 units)
2.5 units / = / ½ pint Carlsberg Special Brew/Kestrel Super/Tennents Super (8-10%)
Note: Low alcohol drinks can still contain 1.2% of alcohol and will still increase your blood alcohol levels. Research shows that no matter what the legal limit it is much safer not to drink and drive at all.
BODY MASS INDEX (BMI) – Only for use by patients aged 16 or over
Clinically, there are few more serious diseases than obesity. Obesity will reduce your life expectancy by six to seven years. It increases your risk of developing diabetes by more than five times and more than doubles your risk of high blood pressure. These are only some of the conditions to consider. Obesity can be treated. Obesity may be indicated from your BMI which can be calculated as follows:
BMI = Weight in kilograms
Height in Metres
e.g. patient weighing 80kg and 1.76m in height = 80 divided by 1.76 divided by 1.76 = 25.8
A BMI of between 18.5 – 24.9 is regarded as normal, 25.0 – 29.9 as overweight, 30.0 and over as obese and 35.0 and over as severe obesity (may differ for patients of certain ethnic origins).
Page 4