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SURGERY WILL BE  CLOSED EVERY THURSDAY FROM 12-1PM FOR PRACTICE MEETINGS-EMERGENCY COVER WILL BE PROVIDED. 


 The Practice Boundary is 8 Miles from the Surgery but excludes the Portadown Area.


 

THE OLD SCHOOLHOUSE MEDICAL CENTRE

New Patient Health Questionnaire

 

Patient Details

 

Title

Mr

 

Mrs

 

Miss

 

Ms

 

Surname

 

Date of Birth

 

First Names

 

Occupation

 

Previous Surnames

 

 

Home Address:

 

 

Post Code:

 

Tel No:                                   

Mobile:

Work:

 

Name and Address of Previous GP:

 

 

 

Ethnic Group

 

 

 

White

 

British

 

 

Irish

 

 

Other (Please specify)

 

 

 

 

Black

 

Caribbean

 

 

African

 

 

Other (Please specify)

 

 

 

 

Asian

 

Indian

 

 

Pakistani

 

 

Chinese

 

 

Other (Please specify)

 

 

 

 

Mixed

 

White & Black Caribbean

 

 

White & Black African

 

 

White & Asian

 

 

Other (Please specify)

 

 

Language

What is your first language?

 

 

 

Proof of Identity

 

 

Birth Certificate

 

Driving Licence

 

Passport

 

Utility Bill

 

Allowance Book

 

Solicitor’s Letter

 

Offer of Tenancy

 

Other

 

 

Please list any medications being taken and the dosages:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you registered disabled?

Yes

 

No

 

 

If yes please give details of your disability: ……………………………………………………………………………

 

………………………………………………………………………………………………………………………………

 

 

Medical Information

 

Please list any serious illnesses/operations/accidents/disabilities (and for women, pregnancy related problems) and the year they took place.

 

 

 

 

Have you ever suffered from? (tick as appropriate)

Epilepsy

Yes

 

No

 

Blindness/Glaucoma

Yes

 

No

 

High Blood Pressure

Yes

 

No

 

Diabetes

Yes

 

No

 

Heart Attack/Stroke

Yes

 

No

 

Depression

Yes

 

No

 

Cancer

Yes

 

No

 

Asthma

Yes

 

No

 

Eczema/Hay Fever

Yes

 

No

 

 

 

 

Are you allergic to any medicines and if so, which ?

Yes

 

No

 

 

 

Have you ever refused treatment/screening of any kind, and if so what?

Yes

 

No

 

 

 

 

Women

 

Have you ever had a cervical smear?

Yes

 

No

 

 

If yes please state when and where: ………..…………………………………………………………………………

 

………………………………………………………………………………………………………………………………

 

Do you smoke?

Yes

 

No

 

If no, have you ever smoked?

Yes

 

No

 

 

If yes how many cigarettes or ounces of tobacco per week? ………………………………………………………

 

Would you like advice on giving up smoking?

Yes

 

No

 

 

 

How much alcohol do you drink in a week?

 

units

(1 unit = ½ pint beer, 1 small glass of wine, 1 single spirit, 1 small glass of sherry or 1 single aperitif)

 

OVER 16’s ONLY

 

Alcohol Users Disorders Identification Test (AUDIT) C

 

Questions

Scoring System

Your Score

0

1

2

3

4

How often do you have a drink that contains alcohol?

 

Never

Monthly or less

2-3 times per month

2-3 times per week

4+ per week

 

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

 

1-2

3-4

5-6

7-8

10+

 

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

 

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

 

 

Your height:

 

 

 

Your weight:

 

 

 

 

BP=

Family History

 

Please state any serious illness, in particular heart disease, strokes, high blood pressure, diabetes or any inherited disease:

 

………………………………………………………………………………………………………………………….

 

………………………………………………………………………………………………………………………….

For Patients aged 65 and over

 

Please give name, address and telephone number 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 a date or ‘never’

 

 

Other information

 

Do you have a carer?

Yes

 

No

 

 

If yes please give details of your carer: ………..…………………………………………………………………………..

 

………………………………………………………………………………………………………………………………….

 

Are you a carer?

Yes

 

No

 

 

If yes please give details of who you care for: ..…………………………………………………………………………..

 

………………………………………………………………………………………………………………………………….

 

(Documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

 

From time to time we may contact you via mobile text message or email, please sign to confirm consent.

 

 

 

Signature:

 

 

 

Date:

 

 

 

 

 
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