New Patient Questionnaire - 3

Last Updated: 04/05/2022

Your Contact Details

Title (optional)

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Previous Surname (optional)

Address

Postcode

Home Number (optional)

Mobile Number

Email Address
Information About You

What is your height?

What is your weight?

What is your first language?

Do you need an interpreter?

Yes

No

Ethnic Group

White British

White Irish

White Other

Black British

Black Caribbean

Black African

Black Other

Asian Indian

Asian Pakistani

Asian Chinese

Asian Other

White & Black British

White & Black Caribbean

White & Black African

White & Asian

Other

Please enter details here
Previous GP

Name and Address of Previous GP
Proof of Identity and Address Provided

Identity Document Type

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Please enter details here

Other (optional)
Medical Information

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

Have you ever suffered from? (tick as appropriate) (optional)

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? (optional)

Please list any medicines being taken and the amount: (optional)

Are you registered disabled?

Yes

No

If yes, please give details (optional)

Are you allergic to any medicines?

Yes

No

If so, which? (optional)

Have you ever refused treatment/screening of any kind?

Yes

No

If so, what and when? (optional)

Have you ever suffered from? (tick as appropriate) (optional)

Anxiety

OCD

Depression

Bipolar Disorder

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

Do you have any other mental health issues?

Yes

No

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

Do you have a carer?

Yes

No

If yes please give details (optional)

Are you a carer?

Yes

No

(If yes please give details) (optional)
Women

Have you ever had a cervical smear?

Yes

No

If 'yes', please state when, where and the result (optional)
Will

Do you hold a Living Will?

Yes

No
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?

Would you like advice on giving up smoking?

Yes

No
Alcohol

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 failed to do what was normally expected of you because of 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

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

Yes

No

Do you want to register for on-line services?

Yes

No

Which Pharmacy would you like your prescriptions to be sent to?

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations?

Yes

No
Signature

Signature

Date
For example, 15 3 1984

Day

Month

Year

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Chapel Group Medical Centre website

New Patient Questionnaire - 3

Your Contact Details

Information About You

Previous GP

Proof of Identity and Address Provided

Medical Information

Carers

Women

Will

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