MEDICAL QUESTIONNAIRE – 19 Beaumont Street Medical Practice
This information may be shared with your College Nurse if you have one.
If you do NOT consent to this please tick the box
Information will not be shared with anyone else without your express consent
Surname
Date of Birth
Forename
Sex
For students
Name of College:
Home Tel No:
Oxford Address:
(NB for students
this will be your
college address)
day
month
/
Female
year
/

Male

Mobile No:
Email Address:
Postcode:
We may use your email address to contact you on matters
relating to your health car
Previous Doctor
For students:
Course / Subject
Address
For students:
Graduation Date
Country of Origin &
Ethnic group
Please tell us about your medical history. This section is important for all new patients but particularly those who
will be coming from outside the UK for the first time as your records will not automatically follow you. There is no
need to mention minor complaints but all significant conditions, operations and injuries should be included, even if
they are now fully resolved. Please include significant emotional or psychological issues if you needed help for them.
Below are three examples of the most helpful format in which to record this information. If you need more space
please continue onto a new page. If there is no significant medical history then please say so.
Date or year
of onset
Name of condition or medical
event
Details of treatment and progress
Is the condition
current? If not, when
did recovery occur?
Examples:1990
Asthma
Salbutamol and Beclomethasone inhalers. Well controlled,
no hospital admissions required.
Ongoing maintenance
treatment.
Fractured right femur due to car
accident.
Internal fixation at such & such hospital by Mr/Dr so & so.
Recovered 1988 but right
leg shortened.
1987
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Do you smoke?
YES / NO
Height:
If YES, how many each day?
If NO, have you ever smoked?
Weight:
YES / NO
Date stopped
PLEASE NOTE THAT THE SURGERY OFFERS
A SMOKING CESSATION SERVICE
Are you taking any medicines / pills / inhalers or using any ointments?
Name of Medicine
(if YES, please give details below)
Dose and Frequency of Use
Date Started
Have you ever used an inhaler (of any type) Yes / No
Have you ever had an adverse reaction or allergy to any medications or other substances? If yes please give details below:Name of medicine or substance
Nature and date of reaction
Below left is the immunisation schedule given to most children in the UK who would now be 18 years old. Please indicate which
immunisations you have had. Please leave blank if you do not have this information.
Age Vaccine
Have you been given
If YES, date
Other
Disease
Date Given
Usually Given
this vaccine?
given
Vaccines
3 times in First
Year of Life
Diphtheria / Tetanus /
Pertussis (DTP or ‘Triple’)
YES / NO / Unknown
MenC
Hib
13 months
Mumps,
1st Dose
Measles,
2nd Dose
Rubella (MMR)
Diphtheria, Tetanus, Polio,
‘Dip / Tet’
YES / NO / Unknown
Pneumococcal
YES / NO / Unknown
Hep A
YES / NO / Unknown
Hep B
10 – 14 years
Heaf Test & BCG (for TB)
YES / NO / Unknown
HPV
13 – 18 years
Diphtheria, Tetanus, Polio
YES / NO / Unknown
Others
Pre-School
3 – 5 years
FOR WOMEN ONLY
Have you ever used any form of
contraception?
Are you using anything currently?
YES / NO
Have you ever had a cervical smear?
(1st smear now recommended age 25)
YES / NO
Date of Last Smear
Are If YES, method used
Result (i.e. normal, abnormal etc)
How long have you used this method?
Was it taken by your GP?
YES / NO
YES / NO
For alternative methods of contraception incl LARC (Long-Acting Reversible Contraception): Please see
www.fpa.org.uk or consult our practice nurse
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ALCOHOL QUESTIONNAIRE
This is a confidential questionnaire about Alcohol consumption. All UK GP Practices are recommended by the
Department of Health to ask all new patients to complete it. It is not compulsory but we would be very grateful for
your co-operation. Its purpose is to identify any patients whose drinking levels are hazardous and to offer help with
this. None of this information is communicated outside the 19 Beaumont Street Team and the results are NOT made
available to the college or the university in any form.
Pint of Regular
Beer/Lager/Cider
Alco pop or
Can of Lager
Questions
Glass of Wine
(175 ml)
Single Measure
of Spirits
Bottle of
Wine
Scoring System
0
1
Never
Monthly or
less
2
2-4 times
per month
3
2-3 times
per week
4
4+ times
per week
How many standard alcoholic units do you
have on a typical day when you are drinking?
How often do you have 6 or more standard
drinks on one occasion?
How often in the last year have you found you
were not able to stop drinking once you had
started?
How often in the last year have you failed to
do what was expected of you because of
drinking?
How often in the last year have you needed
an alcoholic drink in the morning to get you
going?
How often in the last year have you had a
feeling of guilt or regret after drinking?
How often in the last year have you not been
able to remember what happened when
drinking the night before?
Have you or someone else been injured as a
result of your drinking?
1-2
3-4
5-6
7-9
10+
Never
Less than
monthly
Less than
monthly
Monthly
Weekly
Monthly
Weekly
Daily or
almost daily
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Less than
monthly
Monthly
Weekly
Monthly
Weekly
Daily or
almost daily
Daily or
almost daily
Has a relative/friend/doctor/health worker
been concerned about your drinking or
advised you to cut down?
No
How often do you have a drink that contains
alcohol?
Never
Never
No
Yes, but not
in the last
year
Yes, but not
in the last
year
Score
Yes, during
the last year
Yes, during
the last year
TOTAL
SCORE
If you would like to discuss this further or would like some help, the nurses at the surgery would be happy to discuss
this with you. Further information is available at www.nhs.uk.
Thank you very much for your help.
The 19 Beaumont Street Team
IF COMPLETING THIS FORM ELECTRONICALLY PLEASE MAIL BACK TO
registrations.nbs@nhs.net
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