DOCTORS GORDON, HORN AND McLAREN
CROMWELL HARBOUR MEDICAL PRACTICE
NEW PATIENT HEALTH QUESTIONNAIRE
Welcome to our Medical Practice. As it takes time for your records to be transferred from your previous GP we would like you to fill out this questionnaire. This will be discussed when you attend for a new patient health check. Don’t worry if you cannot remember exact dates or details, just do your best! Thank you for you co-operation.
PERSONAL DETAILS
Name ______________________________________________________
Date of Birth______/_______/_______
Home Address_______________________________________________
_____________________________________________________________________________________________________________________________________________________________ Postcode____________
Parent/Guardian Details of Patient_______________________________
Home telephone number_____________________
Day time contact telephone number (mobile or work)________________
Marital Status________________________________________________
(single/married/divorced/live with partner or widow/widower)
Who lives at home with you?___________________________________
______________________________________________________________________________________________________________________
(e.g. wife, husband, children, parents)
Are you a Carer for any of your family members? ______________________________________________________________________________________________________________________
Occupation__________________________________________________
MEDICAL HISTORY
When did you last attend your previous GP surgery?_________________
What for?___________________________________________________
______________________________________________________________________________________________________________________________________________________________________
Have you been attending your previous GP surgery on a regular basis for anything? If yes, please give details______________________________
_________________________________________________________________________________________________________________________________________________________________________________
Are you currently seeing, or waiting to see, a hospital specialist for anything ? If yes, please give details._____________________________
_________________________________________________________________________________________________________________________________________________________________________________
Have you had any serious illnesses or operations?___________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you been in hospital for anything else not already mentioned?
______________________________________________________________________________________________________________________
FAMILY HISTORY
Do any illnesses run in your family? _____________________________
_________________________________________________________________________________________________________________________________________________________________________________
We are specifically interested in high blood pressure, heart disease, stroke, diabetes, asthma and cancer. If any first-degree relatives (mother, father, sister, brother) have died before age 60 please give details.
MEDICATION
Are you taking any regular medication? Please list all prescription drugs and also any drugs you buy from the chemist on a regular basis.
_________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________
ALLERGIES
Do you have any allergies, drug or food intolerances? If yes, please list what you are allergic/intolerant to and what kind of reaction you experienced. ________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________
IMMUNISATIONS
Please list details of any immunisations you have received, if known. Specifically, do you know if you have had a complete course of tetanus or when you last had a tetanus booster? _____________________________
_________________________________________________________________________________________________________________________________________________________________________________
For children under 16 please list childhood immunisations; for children under 5 please bring their Parent held Child Health Record when they are seen. ______________________________________________________
______________________________________________________________________________________________________________________
HEALTH SCREENING (only complete if applicable)
Ladies: When did you last have a cervical smear? __________________ Was it a normal result? ________________________________________ Have you ever had abnormal cervical smears? If yes, please give details. _____________________________________________________
Have you had breast screening (mammogram)? If yes, please give details.
___________________________________________________________
Do you have contraceptive coil or implant at present:________________
Gents: Do you have any prostate problems?_______________________
LIFESTYLE
Do you smoke? If yes, please give details (e.g. cigarettes, pipe, tobacco) and amount._________________________________________________
Have you ever smoked? If yes, how long for, how much and when did you give up? ________________________________________________
Would you be interested in receiving advice about stopping smoking?
Yes____ No____
Do you drink alcohol? If yes, how many units would you estimate per week? 1 unit = 1 measure of spirits or 1 glass of wine or half pint of beer
___________________________________________________________
Do you take any regular exercise? Please give details.________________
_________________________________________________________________________________________________________________________________________________________________________________
Interpreter required? Yes___ No___
Preferred language spoken __________
What is your ethnic group?
A. White - British Irish Other ________________
B. Mixed – White and Black Caribbean
White and Black African
White and Asian
Any other mixed background _________________
C. Asian or Asian British - Indian
Pakistani
Bangladeshi
Any other ___________________
D. Black or Black British – Caribbean
African
Any other___________________
E Chines or other ethnic group - Chinese
Any other __________________
I do not wish to respond
ANYTHING ELSE?
We aim to provide the best medical services to our patients. Is there anything else you think we should know about not covered in the questionnaire? Is there anything you particularly would like to discuss at the new patient health check?___________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you Housebound – Y__N__ Carer – Y__ N__
Preferred Pharmacy – Lloyds__ Aitkens__ Collect__
COMPLETED BY __________________________________________
(please state relationship to patient if not completed by patient)
SIGNATURE_______________________________________________
DATE___________________________
All information given is confidential under the Data Protection Act
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