New Patient Questionnaire Form

Personal Details

Title

Surname *

First Name(s) *

Date of Birth *

Gender *

Male

Female

Address *

NHS Number

Postcode *

Home Telephone Number

Mobile Telephone Number *

Email Address *

Occupation

Marital Status

Next of Kin

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

Contacting You

We require your permission to send SMS/emails to you regarding appointments, test results, health promotion recalls and practice updates

Do we have consent to send text messages to you *

Yes No

Do we have your consent to email you? *

Yes No

Are you a carer? *

Yes No

(If yes please give details)

Do you have a carer? *

Yes No

(If yes please give details)

Information About You

Family History

Please state which member of your family have had any of the following conditions (eg. mother, father, maternal/paternal grandparent etc.)

Asthma

Stroke/tia/cva

Hypertension

CHD

Cancer

Diabetes

Epilepsy

Thyroid Disease

Other

Smoking

Do you smoke? *

Never Smoked

Ex-Smoker

Current Smoker

If you are a current or ex-smoker, please state how many per day *

Would you like advice on giving up smoking? *

Yes No

Alcohol

Please complete the following audit. Unit of alcohol definition: Small glass of wine = 1.5 units Large glass of wine = 3 units 1 bottle = 10 units Pint of beer = 2 units Bottle of beer = 1.7 units Single shot of spirit = 1 unit

Veteran Status

Have you ever served in the Armed Forces? (Please state which branch)

Army Veteran

Military Veteran

Royal Navy Veteran

Royal Marines Veteran

Royal Air Force Veteran

Would you like some information on support available for veterans?

Yes No

Medical History

Known drug allergies *

Other known allergies *

Serious Illnesses *

Previous operations *

Current medications (please list) *

Pharmacy

Please nominate a pharmacy to whom prescriptions can be transferred electronically (with your consent). This can be a pharmacy near your home address or work address. Please note that this will remain unchanged unless you inform us otherwise.

Signature

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New Patient Questionnaire

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