Copy of - New Patient Questionnaire

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Information About You

Previous GP

Name and Address of Previous GP *

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Will

Do you hold a Living Will? *

Yes No

Smoking

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

Alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? One pint of regular larger/beer/cider = 2 units, 1 pint of premium larger/beer/cider = 3 units, alcopop/can/bottle regular lager = 1.5 units, 175ml glass of wine = 2 units, 1 bottle of wine = 9 units *

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? *

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. *

Next of Kin

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

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 *

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Copy of - New Patient Questionnaire

Copy of - New Patient Questionnaire

Further Information