New Patient Health Questionnaire (16 years & over)

TO BE COMPLETED BY ALL PATIENTS 16 YEARS & OVER

This is to enable us to provide continuation of care.  It is therefore important that we obtain certain information in order to do this safely and effectively

Last Updated: 21/03/2024

  • Your Details

    Date of Birth
    For example, 15 3 1984
    Gender (optional)
    Marital Status (optional)

  • CONTACT DETAILS

    By adding a mobile contact we will automatically assume that you consent to receiving appointment reminders and invites by SMS. ** to opt-out of this, please download the appropriate form in the 'forms' section. By adding an email address you will automatically be given core online access to your medical record which includes booking appointments and ordering repeat medication. If you require full access, please download the appropriate form in the 'forms' section

    Preferred method of contact
    Are you currently serving or have you previously served in the Armed Forces?
    If YES, would you be happy for this to be added to your medical record? (optional)
    Is anyone in your immediate family (someone you live with) currently serving or have previously served in the Armed Forces?
    If YES, please tell us who this is (optional)

  • ** IMPORTANT - ACCESSIBLE INFORMATION STANDARD

    Please specify your preferred method of communication
    Do you have any communication/information needs relating to a disability, impairment or sensory loss/issue?

  • ETHNICITY

    Please select
    Do you require an interpreter?

  • GENERAL HEALTH STATUS

    If you do not have a up-to-date Height, Weight, BMI & BP you can attend the surgery and use our Health Monitor in the patient area

    Do you have any health concerns at the moment that you have not previously disclosed to your GP? (optional)

  • ** FEMALES 24yrs & OVER **

    Please give us your latest Cervical Smear status

    Have you had a cervical smear in the past? (optional)
    If YES, what was the date of your last smear? (optional)
    For example, 15 3 1984
    Is there any reason why you do not/ should not have a routine cervical smear? (optional)

  • FAMILY HISTORY

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

  • SMOKING STATUS

    Do you smoke?
    Would you be interested in receiving support to QUIT smoking? (optional)
    Are you currently exposed to smoke at home?
    Are you currently exposed to smoke at work?

  • ALCOHOL STATUS

    *Approx guide - beer/lager (1/2 pint) = 1 to1.5 units, bottled lager/cider (330ml) = 1.7 units, wine (standard glass) = 2 units, spirits (single measure) = 1 unit

    How often do you drink alcohol?
    How many units of alcohol do you drink on a typical day when you have a drink? (see above guide)

  • FOR THE FOLLOWING QUESTION, PLEASE INDICATE THE ANSWER WHICH BEST APPLIES

    1 drink = 1/2 pint beer or 1 glass wine or 1 single spirit

    MEN - How often do you have 8 or more units of alcohol on one occasion? (see above guide) (optional)
    WOMEN - How often do you have 6 or more units of alcohol on one occasion? (see above guide) (optional)
    BOTH - in the last 12 months has a relative or friend, doctor or healthcare worker had a concern about your drinking, or suggested you cut down?

  • DIET & EXERCISE

    Do you add salt to your food after cooking?
    Do you have a varied diet including milk, meat, fruit & vegetables?
    Has your Cholesterol been checked in the last 2 years?
    Do you take regular exercise?
    How often? (optional)

  • CURRENT MEDICATION

    We send ALL our prescriptions electronically to a nominated Pharmacy of your choice. Please specify which Pharmacy you would like this to be sent to (please note. you can change this at any time)

  • ALLERGIES

    Do you have any current allergies?

  • PAST MEDICAL HISTORY

    Please give us details of any current medical conditions or recent treatment or investigations that you have undergone along with the relevant dates.

  • CARERS

    Does anyone look after you and your daily needs in a carer capacity? (optional)
    Are you registered as a carer for someone you look after? (optional)
    Do you care for anyone else as a carer in a non-registered capacity? (optional)

  • THANK YOU FOR COMPLETING THIS HEALTH QUESTIONNAIRE

    To enable us to complete your registration, you must complete and submit the New Patient Registration Form (GMS1). This can be found on the NEW PATIENTS section of our website ** Please note: you will not be registered until we receive this !!

    Please confirm that you have completed and submitted the New Patient Registration form (GMS1)
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