ADULT PATIENT INFORMATION SURVEY
ADULT PATIENT INFORMATION
Date of Registration …………………………………..
Name ………………..…………… Date of Birth …….…………..
Mobile phone ………………………………………………………….
Height …………………………. Weight …….……………………….
Occupation ………………………………………………………………
What is your Ethnic Origin ………………….………………………
Please tick if you do not wish to disclose your
ethnic origin.
Is English your first language Yes / No
If no please state your first language ……………………………
Are you a carer Yes / No
Smoking Status
Never Smoked
Ex – Smoker
Current Smoker How many per day
Alcohol
How many units do you drink on average weekly?
(One unit = ½ beer or lager, glass of wine, pub measure of spirits)
Diet
Do you eat a healthy diet? Yes / No
(Low fat, low sugar, high fibre)
Exercise
|How many times do you exercise each week? |Once | |
| | | |
| |Twice | |
| | | |
| | 3+ | |
| | | |
| Total number of hours weekly: | | |
Please Turn Over (
Allergies Yes / No
If Yes, to what ……………………………………………………………
Family History
Do any members of your close family suffer from:
Heart disease
Stroke
Diabetes
Cancer Where? ………………………………..
Asthma
What medicines, including over the counter are you taking
……………………………………………………………………………….
Female patients only
Date of last smear …………………………………..
Have you ever suffered from :-
Asthma/Bronchitis Yes / No
Heart Problems Yes / No
High Blood Pressure Yes / No
Stroke Yes / No
Diabetes Yes / No
Any other significant illnesses
……………………………………………………………………………….
Thank you
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