Confidential - Health Questionnaire for New Patients Patient Number:
Personal Details: Family Name:
First Name:
Date of Birth:
Telephone Number: Home:
Telephone Number: Work:
Telephone Number: Mobile:
Email Address:
Gender: Please choose... Male
Female
Next of Kin (Name):
Contact No:
Personal Status: Please choose... Single
Married
Seperated
Civil Partnership
Divorced
Widowed
Co-habiting
General Needs Do you need support with spoken english? Please choose... Yes
No
Do you consider yourself to have a disibility? Please choose... Yes
No
Do you help and support someone on a regular basis? Please choose... Yes
No
Does anyone help and support you on a regular basis? Please choose... Yes
No
Interpreter required: Please choose... Yes
No
Which language do you require a interpreter for?
Sign Language: Please choose... Yes
No
Hearing Aid: Please choose... Yes
No
Are you a Carer? Please choose... Yes
No
Are you any of the following? Please choose... Homeless
Refugee
Asylum Seeker
Ethnic Origin Black or Black British Please choose... Caribbean
African
Any other black background:
Mixed Please choose... White and black Caribbean
White and black African
White and Asian
Any other mixed background:
White Please choose... British
Irish
Any other White background:
Asian and Asian British Please choose... Indian
Pakistani
Bangladeshi
Any other Asian background:
Chinese or other Ethnic groups Please choose... Chinese
Vietnamese
Any other ethnic group:
Present and Past Illnesses Have you any current or past medical problems? Please choose... Yes
No
If Yes, please give Dates/Details:
Is there a history of alcohol misuse? Please choose... Yes
No
Is there a history of drugs misuse? Please choose... Yes
No
Do you suffer from any allergies? Please choose... Yes
No
If so, please state including medication:
Are you taking any regular medication including the contraceptive pill? Please choose... Yes
No
Name and dose of medication:
Family Medical History Heart attack or Angina: Please choose... Yes
No
Stroke: Please choose... Yes
No
Sugar Diabetes: Please choose... Yes
No
Asthma: Please choose... Yes
No
High Blood Pressure: Please choose... Yes
No
Cancer: Please choose... Yes
No
If yes, please state which family member and which type of cancer they had:
Is there any history of domestic violence and/or involvement with social services? Please choose... Yes
No
BMI - Body Mass Index Height:
Weight:
Blood Pressure:
Life Style - We provide a stop smoking clinic for registered patients. Do you smoke? Please choose... Yes
No
What year did you start smoking?
Are you an ex smoker? Please choose... Yes
No
What year did you stop smoking?
Cigerettes? Please choose... Yes
No
No. per day?
Cigars/Pipes? Please choose... Yes
No
No. per day?
Roll-ups? Please choose... Yes
No
No. per day?
Drinking How often do you have a drink that contains alcohol? Please choose... Never
Monthly or Less
2-4 times per month
2-3 times per week
4+ times per week
Scoring System - Never = 0, Monthly or Less = 1, 2-4 times per month = 2, 2-3 times per week = 3, 4+ times per week = 4 Your Score
How many standard alcoholic drinks do you have on a typical day? Please choose... 1-2
3-4
5-6
7-8
10+
Scoring System - 1-2 = 0, 3-4 = 1, 5-6 = 2, 7-8 = 3, 10+ = 4 Your Score
How often do you have 6 or more standard alcoholic drinks on one occasion? Please choose... Never
Less than Monthly
Monthly
Weekly
Daily or almost daily
Scoring System - Never = 0, Less than Monthly = 1, Monthly = 2, Weekly = 3, Daily or almost daily = 4 Your Score
Scoring System - Scoring: A total of 5+ indicates hazardous or harmful drinking Exercise Do you take regular exercise? Please choose... Yes
No
HIV Screening We provide HIV screening to newly registering patients Women only When was your last smear/PAP smear done? (Date):
Have you had a Hysterectomy? Please choose... Yes
No
Aged 16-24: Are you interested in Chlamydia screening? Please choose... Yes
No
Patients Signature †
Date