New Patient Questionnaire New Patient Questionnaire YOUR CONTACT DETAILSTitleMrMissMrsMsOtherName Date of birth MM slash DD slash YYYY Previous Surname Optional Address Postcode Home Number OptionalMobile Number OptionalEmail Address Optional INFORMATION ABOUT YOUWhat is your height? What is your weight? What is your first language? Do you need an interpreter? Yes No Ethnic GroupWhite BritishWhite IrishWhite OtherBlack BritishBlack CaribbeanBlack AfricanBlack OtherAsian IndianAsian PakistaniAsian ChineseAsian OtherWhite & Black BritishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOtherPREVIOUS GPName and Address of Previous GPPROOF OF IDENTITY AND ADDRESS PROVIDEDIdentity Document TypeBirth CertificateDriving LicencePassportUtility BillAllowance BookSolicitors LetterOffer of TenancyMEDICAL INFORMATIONPlease list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took placeHave you ever suffered from? (select as appropriate) Epilepsy Optional Blindness/Glaucoma Optional High Blood Pressure Optional Diabetes Optional Heart Attack/Stroke Optional Depression Optional Cancer Optional Asthma Optional Eczema/Hay Fever Optional COPD Optional If yes, please state the year(s) when you were first diagnosed? Optional Please list any medicines being taken and the amount: OptionalAre you registered disabled? Yes No If yes, please give details Optional Are you allergic to any medicines? Yes No If so, which? Optional Have you ever refused treatment/screening of any kind? Yes No If so, what and when? Optional Have you ever suffered from? (select as appropriate) Anxiety Optional OCD Optional Depression Optional Bipolar Disorder Optional If yes to any of these, please state the year(s) when were you first diagnosed? Optional Do you have any other mental health issues? Yes No Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it) Optional CARERSDo you have a carer? Yes No If yes, please give details OptionalAre you a carer? Yes No If yes, please give details OptionalWOMENHave you ever had a cervical smear? Yes Optional No Optional If yes, please state when, where, and the result Optional WILLDo you hold a living will? Yes No SMOKINGDo you smoke? Yes No Have you ever smoked? Yes No If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? Optional Would you like advice on giving up smoking? Yes Optional No Optional ALCOHOLMEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?NeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking?NeverLess than monthlyMonthlyWeeklyDailyIn the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?NoYes, on one occasionYes, more than onceFAMILY HISTORYPlease 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 KINPlease give name, address, telephone number and relationship of next of kinFOR PATIENTS AGED 65 AND OVER OR THOSE WITH A CHRONIS DISEASE (E.G. ASTHMA OR DIABETES)Have you had a flu vaccination? Enter date or 'never' Optional Have you had a pneumococcal vaccination? Enter date or 'never' Optional CONTACTING YOUDo 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 SIGNATURESignature Date MM slash DD slash YYYY