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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download