New patient questionnaire - The Ridings Medical Group
New patient questionnaire
This questionnaire forms part of your registration process and must be completed before we can register you. New patients have the opportunity for a new patient appointment please ask at reception if you wish to book in for one of these appointments.
|Personal details |
|Name: | |Today’s Date: | |
|Date of Birth: | | | |
|Telephone No. (home) | |Telephone No. (work) | |
|Mobile No. | |Consent to text message reminders: |Yes ( No ( |
|I consent to receiving appointment confirmations, reminders and other notices via text messages and will update the Surgery of any |
|changes to my mobile number. I have read the terms and conditions.* |
|Signature | |Date | |
|Email Address | |
|Medical details |
|Height: | |Weight: | |
|Please use the Self check BP Machine or at Holme and Bubwith book Bp appt |
|Blood pressure (Age 40 and Over Only) BP …………./…………. Date taken: |
|Past medical history |
|Please detail any significant past medical | |
|history that you feel we should be informed of: | |
|Family history (Please indicate relationship and age at onset) |
|Please detail any significant family history that| |
|you feel we should be informed of (e.g. asthma, | |
|diabetes, epilepsy, stroke, heart attack, | |
|cancer): | |
|Medication – If you are on any repeat medication please book an appointment to see a GP before your next medication is due |
|Please list any prescribed medication you are |(Please attach a copy of your repeat prescription list if possible) |
|currently taking: | |
|Over the counter medication |
|Please list any over the counter medication that | |
|you take on a regular basis: | |
|Allergies (including drug allergies) |
|Please list any allergies you have: | |
|Lifestyle questions |
|Smoking status Please tick one of the following: |
|( Current smoker ( Ex-smoker ( Never smoked tobacco |
|If you are a current / ex-smoker, how many cigarettes/ ounces per day? |
|If you are an ex-smoker, what year did you give up smoking? |
|If you are a smoker there are various free stop smoking services in the Hull and East Riding areas. For further information and help on |
|quitting please call 0800 915 59 59 (freephone number). |
|Alcohol: units per week |
Alcohol Consumption Screen
Units of alcohol
| |1.5 | | | |
| | | | | |
| | | | | |
| | | | | |
|2 | |2 |1 |9 |
|Pint of beer, lager or |Alco pop or can of lager|Glass of wine 175ml |Single measure of spirit |Bottle of wine |
|cider | | | | |
|Questions |Scoring scheme |Enter score |
| | |below |
| |
|First Language: | |
|Country of Origin | |When did you last visit your country of origin? …… yrs |
|Have you ever served in the Armed forces? |Yes / No |
|Are you a carer of Yes / No |Are you housebound? Yes / No |
|An elderly or disabled person? | |
|ENHANCED SUMMARY CARE RECORD (ESCR) |
|The NHS in England has introduced the Summary Care Record, which will be used in emergency care. |
| |
|The record will only contain information about any medicines you are taking, medical history, allergies you suffer from and any bad reactions to |
|medicines you have had to ensure those caring for you have enough information to treat you safely. |
| |
|Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission |
|before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important |
|information about your health. |
| |
|If you would like an Enhanced Summary Care Record then you do not need to do anything and a Summary Care Record will be created for you. If you do |
|not want a Summary Care Record then tick the box and sign the opt out below. |
| |
|I do NOT want a Summary Care Record (tick Box) ( |
| |
|Signature: DATE: |
-----------------------
|WHITE |
|British | |
|Irish | |
|Any other white Background* | |
|ASIAN OR ASIAN BRITISH |
|Indian | |
|Pakistani | |
|Bangladeshi | |
|Any other Asian background* | |
|MIXED |
|White and Black Caribbean | |
|White and Black African | |
|White and Asian | |
|Any other mixed background | |
|BLACK OR BLACK BRITISH |
|Caribbean | |
|African | |
|Any other black background | |
|OTHER ETHNIC GROUPS |
|Chinese | |
|Any other ethnic group | |
|Decline to Specify | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- new patient health questionnaire forms
- west florida medical group patient portal
- new patient questionnaire printable form
- new patient questionnaire template
- florida hospital medical group patient portal
- advent health medical group patient portal
- family medical group patient portal
- altamonte medical group patient portal
- sacred heart medical group patient portal
- ascension medical group patient portal
- memorial medical group patient portal
- adventhealth medical group patient portal