New Patient Questionnaire V2

You MUST fill in this questionnaire to complete your new patient registration. You WILL NOT be registered until this has been completed in full. This helps us find out more about your medical needs, and thus enables us to provide the required care and support you may need and improve the services we offer. This information is confidential and will NOT affect your registration. We would be grateful if you could make sure you complete the alcohol questionnaire at the bottom of the second page.

Last Updated: 18/06/2021

Your Contact Details

Title

First Name *

Surname *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Work Number

Email Address *

Status *

Single

Married

Living with partner

Divorced

Widowed

Next of kin contact details *

Your relationship to next of kin - example: mother/partner/aunt *

Do you have any disabilities or any special information or communication requirements? *

Yes No

If so, please detail them

Would you be interested in joining our patient Participation Group? *

Yes No

Information About You

Proof of Identity and Address Provided

Medical Information

This is about your past medical history and current medical needs

Carers

Do you have a carer? *

Yes No

Do you have a care agency supporting you at home?

Yes No

If yes, please give their name and contact details:

Are you a carer? *

Yes No

(If yes please give details)

FOR WOMEN ONLY

Please complete where appropriate

Have you ever had a cervical smear?

Yes No

If YES, please state when, where and the result

Have you ever been pregnant?

Yes No

If so - how many pregnancies and the dates?

Did you have any associated difficulties with your pregnancy? If so, please give details and dates:

Smoking

Do you smoke? *

Yes No

Do you Vape *

Yes No

If 'No', have you ever smoked?

Yes No

If YES. when did you give up?

If you do currently smoke, how many cigarettes do you smoke per week?

If you do currently smoke, how many grams of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes No

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

How often do you have a drink containing alcohol? *

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

How often do you have 6 or more standard drinks on one occasion?

How often in the last year have you found you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected of you because of drinking?

how often in the year have you needed an alcoholic drink in the morning?

How often during the last year have you had a feeling of guilt or regret after drinking?

How often in the last year have you not been able to remeber what happened when drinking the night before?

have you or someone else been injured as a result of your drinking?

Has a relative or friend, or a doctor or other health worker been concerned about your drinking or advised you cut down?

Family History

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.

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

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

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

Contacting You

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

Signature *

Date *

New Patient Questionnaire V2

Further Information