New Patient Health Questionnaire for Adults

About This Form

Some fields are compulsory.

By using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your details.

Confidentiality

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.

Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.

If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

 

Your Contact Details
Information About You
Previous GP

Name and Address of Previous GP

Proof of Identity and Address Provided
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

Blindness/Glaucoma

High Blood Pressure

Diabetes

Heart Attack/Stroke

Depression

Cancer

Asthma

Eczema/Hay Fever

COPD

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

Please list any medicines being taken and the amount:

Are you registered disabled? (If yes, please give details)

Are you allergic to any medicines and if so, which?

Have you ever refused treatment/screening of any kind and if so, what and when?

Medical Informaton continued

Have you ever suffered from? (tick as appropriate)

Anxiety

Depression

OCD

Bipolar Disorder

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

Are you a carer? (If yes please give details)

Will

Do you hold a Living Will?

(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?(If ‘yes’, please state when, where and the result)

Smoking

Do you smoke?

If ‘No’, have you ever smoked?

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?

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
Signature

Signature


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

Date



CORONAVIRUS (COVID-19) ADVICE

Do not leave home if you or someone you live with has either a high temperature or a new, continuous cough or loss/change to sense of smell or taste.

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