New Patient Questionnaire YOUR CONTACT DETAILSTitlePlease SelectMrMrsMissMsOtherName First Last Date of Birth DD slash MM slash YYYY Previous Name First Optional Last Optional Address Street Address Address Line 2 City State / Province / Region Post Code Contact NumberEmail Optional INFORMATION ABOUT YOUWhat is your height? * What is your weight? What is your first language? Do you need an interpreter? Yes No Ethnic GroupPlease SelectWhite BritishWhite IrishWhite OtherBlack BritishBlack CaribbeanBlack AfricanBlack OtherAsian IndianAsian PakistaniAsian ChineseAsian OtherWhite & Black BritishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianotherPREVIOUS GPName and Address of Previous GP PROOF OF IDENTITY AND ADDRESS PROVIDEDIdentity Document TypePlease SelectBirth CertificateDriving LicencePassportUtility BillAllowance BookSolicitors LetterOffer of TenancyOtherOther MEDICAL INFORMATIONPlease 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 None 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? 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) Anxiety Optional OCD Optional Depression Optional Bipolar Disorder Optional 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) OptionalCARERSDo you have a carer? Yes No If yes please give details OptionalAre you a carer? Yes No (If yes please give details) OptionalWOMENHave you ever had a cervical smear? Yes No If 'yes', please state when, where and the result OptionalWILLDo you hold a Living Will? Yes No SMOKINGDo you smoke? 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? * ALCOHOLMEN: 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?Please SelectNeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking?Please SelectNeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking?Please SelectNeverLess than monthlyMonthlyWeeklyDailyIn 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 SelectNoYes, On one OccasionYes, more than OnceFAMILY HISTORYPlease 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 KINPlease give name, address, telephone number and relationship of next of kinFOR 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 YOUDo 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 SIGNATURESignature Date DD slash MM slash YYYY