New Patient Questionnaire 2024

Last Updated: 14/11/2024

Your Contact Details

Title (optional)

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Address

Postcode

Home Number (optional)

Mobile Number

Email Address (optional)

Marital status (optional)

Occupation (optional)
We are expected to ask this question and we accept you may wish to decline

Ethnicity (optional)

White

Chinese

Black Caribbean

Pakistani

Black African

Indian

Mediterranean

Bangladeshi

Other

Please enter details here

Preferred language (optional)

English

Welsh
Consent

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccination reminders, to let you know a prescription is ready for collection, test results or anything else that may be relevant to your care?

Yes

No
Medical Information

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

Asthma

Diabetes

Epilepsy

Thyroid problems

Stroke

Mental health problems

Cancer

Blindness/Glaucoma

Heart Attack

Angina

High Blood Pressure

If yes, please state the year(s) when were you first diagnosed and any details (optional)

Have any family members suffered from any of the conditions above? If YES, please give details (optional)

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

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

Do you have any disabilities? If yes, please give details and ways you may need assistance (optional)

Do you have any allergies?

Yes

No

If yes, please give details (optional)
Vaccination history

Have you had any of the following childhood vaccinations? (optional)

Diphtheria

Tetanus

Polio

Measles

Mumps

Rubella

Whooping cough

When was your last tetanus vaccination? (optional)
Smoking

Do you smoke?

Yes

No

If 'No', have you ever smoked? (optional)

Yes

No

If you do currently smoke, how many cigarettes or grams of tobacco do you smoke per week? (optional)
Alcohol

If yes, how many units per week (where 1 standard 175ml glass of wine is 2 units/1 standard pint of 5% alcohol larger is 3 units) (optional)

Do you drink alcohol?

Yes

No
Diet

How would you describe your diet? (optional)

Good

Average

Poor

Vegetarian

Vegan

Low fat

Low sugar

Gluten free

How would you describe your daily activity level?

Sedentary

Lightly active

Very active

If know, what is your height? (optional)

If known, what is your weight? (optional)

If known, what is your BMI? (optional)
Please note, we may contact you to offer advice or support based on your submission
Carers

Do you need/have anyone who looks after you or your daily needs as a carer?

Yes

No

Are they a patient here? (optional)

Yes

No

If yes, would you like them to deal with your health affairs? (optional)

If yes, please give their details (Full name, address and phone number) (optional)

Are they a patient here? (optional)

Yes

No

Are you a carer for someone?

Yes

No
Military Veteran

Have you ever served in the armed forces?

Yes

No
Communication

Do you have any communication needs relating to sensory loss? If so, what are they and how would you like us to communicate with you? (optional)
Thank you for taking the time to complete this form, this will help us provide the appropriate care for you, whilst we await your medical notes from your prevrious practice.

If you would like anyone else to act on your behalf, access your records or collect your prescriptions, please ask a member of the reception team for a consent form.

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New Patient Questionnaire 2024

Your Contact Details

We are expected to ask this question and we accept you may wish to decline

Consent

Medical Information

Vaccination history

Smoking

Alcohol

Diet

Please note, we may contact you to offer advice or support based on your submission

Carers

Military Veteran

Communication

Thank you for taking the time to complete this form, this will help us provide the appropriate care for you, whilst we await your medical notes from your prevrious practice.