New Patient Questionnaire V3 06/03/2023

Title

Do you have private health insurance

Yes No

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number (Please put none if no home number) *

Mobile Number (Please put none if no mobile number) *

Email Address (Please put none if no email address) *

What is your height? *

What is your weight? *

What is your first language? *

Do you need an interpreter? *

Yes No

Ethnic Group *

Name and Address of Previous GP *

Have you ever suffered from? (tick as appropriate) *

If yes, please state the year(s) when were you first diagnosed?

Are you registered disabled? *

Yes No

If yes, please give details

Are you allergic to any medicines? *

Yes No

If so, which?

Have you ever suffered from? (tick as appropriate) *

Anxiety

OCD

Depression

Bipolar Disorder

Not applicable

If yes to any of these, please state the year(s) when were you first diagnosed?

Do you have any other mental health issues? *

Yes No

If yes, please give details

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it) *

Do you have a carer? *

Yes No

If yes, please give details of who cares for you.

Do you give permission for us to discuss your medical records with them?

Yes No

Are you a carer? *

Yes No

If yes please give details

Have you ever had a cervical smear? *

If 'yes', please state when, where and the result

Do you hold a Living Will? *

Yes No

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes No

How often do you have an alcoholic drink? *

How many alcoholic drinks would you usually have when you drink? *

How often do you have 6 or more alcoholic drinks in a day? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Please give name, address, telephone number and relationship of next of kin *

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Signature *

Date *

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New Patient Questionnaire V3 06/03/2023

Further Information