The McGlone Practice
BAILLIESTON
NEW PATIENT MEDICAL QUESTIONNAIRE
TWO FORMS OF IDENTIFICATION MUST BE
PROVIDED
ONE PHOTOGRAPHIC & ONE WITH CURRENT
ADDRESS AND A COPY OF YOUR MOST RECENT
PRESCRIPTION REQUEST FORM
FORMS MUST BE FULLY COMPLETED BEFORE
HANDING IN
PATIENT NAME
PREVIOUS SURNAMES
DATE OF BIRTH
ADDRESS
Have you previously been a patient with this practice? ________
TELEPHONE NUMBER
MOBILE NUMBER
OUR STAFF WILL BE HAPPY TO HELP YOU COMPLETE THIS FORM
OFFICE USE ONLY
FORM CHECKED BY ________________________________________
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ALL ABOUT YOU
HEIGHT
WEIGHT
__________
__________
TO WHICH ETHNIC GROUP DO YOU BELONG – PLEASE TICK APPROPRIATE BOX
WHITE □
CHINESE □ ASIAN □ BLACK □ OTHER□___________
Do you have any registered disability/communication problems?
Please specify:
DO YOU SUFFER FROM ANY OF THE FOLLOWING?
PLEASE TICK ALL THAT APPLY.
DATE OF DIAGNOSIS
ASTHMA
_________________
COPD
_________________
DIABETES
_________________
HIGH BLOOD PRESSURE
_________________
ISCHAEMIC/CORONARY HEART DISEASE
_________________
ANGINA
_________________
OSTEOPOROSIS
_________________
EPILEPSY
_________________
OSTEOARTHRITIS
_________________
THYROID DISEASE
_________________
HEPATITIS
_________________
Stroke________________________________________________________
PLEASE MAKE 30 MIN APPT FOR VALERIE IF YOU HAVE ANY CHRONIC DISEASE
DO YOU SUFFER FROM ANY OTHER ILLNESSES?
APPROXIMATE DATE OF ONSET
1.
2
3.
4.
5.
6.
PLEASE LIST THEM BELOW WITH AN
.
HAVE YOU HAD ANY OPERATIONS? PLEASE LIST THEM BELOW WITH DATE OF PROCEDURE
1.
2.
3.
4.
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MEDICATION
ARE YOU ALLERGIC TO ANY MEDICATION? PLEASE LIST
1.
2
3.
4.
5.
.
DO YOU HAVE ANY OTHER ALLERGIES? PLEASE LIST.
1.
2.
3.
4.
5.
PLEASE
PLEASE
PLEASE
PLEASE
LIST ALL MEDICATION YOU ARE CURRENTLY TAKING.
INCLUDE DOSES AND HOW OFTEN YOU TAKE THE MEDICATION.
INCLUDE MEDICINES BOUGHT OVER THE COUNTER.
BRING ALL MEDICATION WITH YOU TO YOUR APPOINTMENT.
1.
2.
3.
4.
5.
6.
7.
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14 YEARS AND OVER ONLY
OCCUPATION
……………………………………………………………………………………………….
YOUR SOCIAL HABITS
HOW WOULD YOU DESCRIBE YOURSELF? PLEASE TICK ALL THAT APPLY.
SMOKING
NEVER SMOKED
EX SMOKER
CURRENT SMOKER
ALCOHOL
GIVEN THAT THE CURRENT GUIDELINES FOR ALCOHOL INTAKE ARE A MAXIMUM
3-4 UNITS PER DAY FOR MEN AND 2-3 UNITS PER DAY FOR WOMEN HOW WOULD YOU DESCRIBE
YOURSELF?
1 UNIT IS EQUIVALENT TO ½ PINT NORMAL STRENGTH BEER OR LAGER
ONE GLASS OF WINE
A SINGLE PUB MEASURE OF SPIRIT.
TEETOTALLER
NO LONGER DRINK ALCOHOL
DRINK WITHIN RECOMMENDED LIMITS
DRINK ALCOHOL TO EXCESS
EXERCISE
NEVER EXERCISE DUE TO PHYSICAL PROBLEMS
AVOID EVEN TRIVIAL EXERCISE
ENJOY LIGHT EXERCISE E.G WALKING, LIGHT HOUSEWORK
ENJOY MODERATE EXERCISE E.G. HOUSEWORK, GARDENING
ENJOYS STRENUOUS EXERCISE E. G HEAVY MANUAL WORK, SPORT
COMPETITIVE ATHLETE
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YOUR FAMILY
DO ANY MEMBERS OF YOUR CLOSE FAMILY (GRANDPARENTS, PARENTS, AUNTS,
UNCLES, BROTHERS, AND SISTERS) SUFFER FROM THE FOLLOWING?
RELATIONSHIP ?
ASTHMA________________
COPD
______
DIABETES
HIGH BLOOD PRESSURE
ANGINA
HEART ATTACK
THYROID DISEASE
STROKE
BREAST CANCER
OVARIAN CANCER
OTHER CANCER
OSTEOPOROSIS
EPILEPSY_______________
RHEUMATOID ARTHRITIS___
___________________________
___________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
DO ANY OTHER HEALTH PROBLEMS RUN IN YOUR FAMILY?
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