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

Title

Surname

DOB

First name

Occupation

Previous Surname

Address

Home Tel

Post Code

Work Tel

Mobile Tel

Information About You

What is your height?

What is your weight?

What is your first language?

Do you need an interpreter? *

an interpreter?

Yes No

Ethnic Group *

White

White

British Irish Other

If other please specify

Black

Black groups

Caribbean African Other

If other please specify

Asian

Asian groups

Indian Pakistani Chinese Other

If other please specify

Mixed

Mixed groups

White + Black Caribbean White + Black African White + Asian Other

If other please specify

Previous GP

Name and Address of Previous GP

Previous GP

Proof of Identity and Address Provided

If Other

Medical Information

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place

list any serious illnesses

Have you ever suffered from? (tick as appropriate)

Epilepsy

Yes No

Blindness/Glaucoma

Yes No

High Blood Pressure

Yes No

Diabetes

Yes No

Heart Attack/Stroke

Yes No

Depression

Yes No

Cancer

Yes No

Asthma

Yes No

Eczema/Hay Fever

Yes No

COPD

Yes No

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

state the year(s)

Please list any medicines being taken and the amount:

Please list medicine & amount

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

Registered Disabled

Yes No

Registered Disabled Details

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

AlergicToMedicine

Yes No

Alergic to medicine Details

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

refused Treatment

Yes No

refused treatment details

Medical Informaton continued

Have you ever suffered from? (tick as appropriate)

Anxiety

Yes No

Depression

Yes No

OCD

Yes No

Bipolar Disorder

Yes No

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

If yes to any of these

Do you have any other mental health issues? (If yes please give details)

mental health issues

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

treatment or therapy?

Carers

Do you have a carer? (If yes please give details)

have a carer?

Yes No

have a carer?Yes

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

are a carer?

Yes No

are a carer?Yes

Will

Do you hold a Living Will?

Will?

Yes No

(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)

cervical smear?

Yes No

cervical smear?Yes

Smoking

Do you smoke?

Yes No

If ‘No’, have you ever smoked?

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

do you smoke per week?

Would you like advice on giving up smoking?

Would you like advice?

Yes No

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?

Alcohol Intake Men & Women

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Alcohol Intake during last year

How often during the last year have you failed to do what was normally expected of you because of drinking?

Failed due to Alcohol Intake during last year

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?

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.

Family History Details

Next of Kin

Please give name, address, telephone number and relationship of next of kin

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’:

Had Flu?

Have you had a pneumococcal vaccination? Enter date or ‘never’:

had pneumococcal?

Contacting You

contact agreement

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. Signature

Signature

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

Date

New Patient Health Questionnaire for Adults

About This Form

Confidentiality

Personal Information

Your Contact Details

Information About You

Previous GP

Proof of Identity and Address Provided

Medical Information

Medical Informaton continued

Carers

Will

Women

Smoking

Alcohol

Family History

Next of Kin

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Contacting You

Signature

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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