New Patient Health Questionnaire for Adults

Contact Details

Title

Surname

First Names

Date of birth

Previous surnames

Occupation

Home phone

Mobile phone

Work phone

Home address

Postcode

Email address

Please provide an email address where possible

Information about you

What is your height?

What is your weight?

What is your first language?

Do you need an interpreter? Yes No

Ethnic Group *

White British Irish Other

If other please specify

Black Caribbean African Other

If other please specify

Asian Indian Pakistani Chinese Other

If other please specify

Mixed

White + Black Caribbean

White + Black African

White + Asian

Other

If other please specify

Previous GP

Name and Address of Previous GP

Proof of identity and address provided

Birth certificate

Driving licence

Passport

Utility bill

Allowance book

Solicitor's letter

Offer of tenancy

Other

If other please specify

Medical information

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

Have you ever suffered from? (tick as appropriate)

Epilepsy Yes No

High blood pressure Yes No

Heart attack/Stroke Yes No

Cancer Yes No

Eczema/Hay fever Yes No

Blindness/Glaucoma Yes No

Diabetes Yes No

Depression Yes No

Asthma Yes No

COPD Yes No

If yes, please state the year(s) when you were first diagnosed?

Please list any medicines being taken and the amount:

Are you registered disabled? Yes No

If yes, please give details

Are you allergic to any medicines? Yes No

If so, which?

Have you ever been refused treatment/screening of any kind? Yes No

If so, what and when?

Medical information continued

Have you ever suffered from? (tick as appropriate)

Anxiety Yes No

Depression Yes No

OCD Yes No

Bipolar disorder Yes No

If yes to any of these, please state the year(s) when you were first diagnosed?

Do you have any other mental health issues? (If yes please give details)

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

Carers

Do you have a carer? Yes No

If yes, please give details

Are you a carer? Yes No

If yes, please give details

Will

Do you hold a Living Will? Yes No

(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

Women

Have you ever had a cervical smear test? Yes No

If 'yes', please state when, where and the result

Smoking

Do you smoke? Yes No

If no, have you ever smoked? Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking? Yes No

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits

MEN: 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?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In 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?

Family History

Please 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 kin

Please give name, address, telephone number and relationship 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 date or 'never'

Contacting You

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Signature

Signature & Date
(you will be asked to sign this form when you visit the practice)

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New Patient Health Questionnaire for Adults

Thank you for completing the questionnaire.

About This Form

Personal Information