Shared/reception/forms/116105534
PATIENT HEALTH QUESTIONNAIRE
Please Note: We will require photo proof of ID to register you as a patient (ie: passport or driving
licence)
Full Name: ______________________________________ Date of Birth: ____________
Telephone No.: ________________________ Mobile No:________________________
We now offer a SMS text reminder service, would you like to receive a text reminding you of
forthcoming appointments at the surgery? Yes / No (please delete as appropriate)
Height: ____________________
Sex: M/F
Weight: ______________________
Address: ________________________________________________________________
_________________________________________ Post Code: ____________________
First Language spoken: __________________
Were you previously a patient? :
Y/N
Ethnicity_____________________
Marital Status:______________________
Past Medical History: (Please circle Y – yes or N – no)
Asthma
Y/N
Chronic Bronchitis/COPD
Y/N
Heart Disease Y/N
Stroke
Y/N
Cholesterol Problems
Y/N
Diabetes
Y/N
Epilepsy
Y/N
Thyroid Problems
Y/N
Cancer
Y/N
High Blood Pressure
Y/N
Other operations or long term illness etc: ______________________________________
Please list any current medication prescribed by your doctor
1. __________________________________
2. ____________________________
3. __________________________________
4. ____________________________
9. __________________________________
10.____________________________
Do you have any drug / other allergies (Please list):
Are you currently using any form of contraception Y/N
If Yes, what type _________
Are you a current/ ex / non smoker (please circle)
If so, how many cigarettes do you smoke per day _____________
Are you: very active moderately active
moderately inactive
Do you require information about healthy eating
inactive
(please circle)
Y/N
Do you use any non prescribed drugs Y/N If yes, what __________________________
Have you had a tetanus in the last 10 years
Y/N Don’t know (Please circle)
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Shared/reception/forms/116105534
Have you had a flu jab in the last 12 months
Y/N Don’t know (Please circle)
Have you had a Pneumonia jab in the last 10 years
Y/N Don’t know (Please circle)
Carers Information
Do you care for someone? Y/N
Does someone care for you? Y/N
Units of Alcohol drunk on an average week: ……………………………………….
Alcohol Intake
0
1
2
3
4
How often do you
have a drink that
contains alcohol
Never
Monthly
or less
2-4 times
per month
2-3 times
per week
4+ times
per
week
How many standard
alcoholic drinks do
you have on a
typical day when
drinking?
1-2
3-4
5-6
7-8
10+
How often do you
have 6 or more
standard drinks on
one occasion
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Your
Score
Family Medical History – Do any of your family suffer from any of the following:
Diabetes
Y/N
Relation
High Blood Pressure
Y/N
Relation
Asthma
Y/N
Relation
Stroke
Y/N
Relation
Epilepsy
Y/N
Relation
Chronic Bronchitis/ COPD
Y/N
Relation
Females only
Date of last smear_____________________ Method of contraception_______________
Dates of birth of children___________________________________________________
Date:_______________________
Patient Signature____________________________
NB: Patients outside of the practice area will only be accepted onto the Practice List at the
discretion of the partners. You will be notified within 3 weeks of you application to join the
practice.
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