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 | |
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Home Address: |
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Post Code: |
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Tel No: | Mobile: | Work: |
Name and Address of Previous GP: |
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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: ………..…………………………………………………………………………..
………………………………………………………………………………………………………………………………….
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.