New Patient Questionnaire Form - Coventry Road Medical Centre

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

What is your height? *

What is your weight? *

What is your first language? *

Do you need an interpreter? *

Yes No

Ethnic Group *

Name and Address of Previous GP *

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

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)

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? *

Yes No

If yes, please give details

Are you allergic to any medicines? *

Yes No

If so, which?

Have you ever refused treatment/screening of any kind? *

Yes No

If so, what and when?

Have you ever suffered from? (tick as appropriate)

Anxiety

OCD

Depression

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? *

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)

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Do you hold a Living Will? *

Yes No

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

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? *

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? *

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. *

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

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

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

Signature *

Date *

New Patient Questionnaire V2

New Patient Questionnaire V2

Further Information

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New Patient Questionnaire V2

New Patient Questionnaire V2

Further Information