New Patient Health Questionnaire
Kilbeggan Medical Centre
Tel: 057 9332444
Patient Details
Title
□Mr. □Mrs. □Miss □Ms. □ Other
Surname
___________________________________________________
If under 18 – Mum’s surname _____________ Dad’s surname ____________
First Names ______________________________________________________
Previous Surnames _____________________________________________
Date of Birth ___________________________________________________
Occupation ___________________________________________________
Home Address _________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Home Tel
___________________________________________________
Work Tel
___________________________________________________
Mobile
___________________________________________________
Do you wish to receive text reminders for appointments
□Yes
□No
e-mail address _________________________________________________
What is your first language? _______________________________________
Name and Address of Previous GP _________________________________
___________________________________
___________________________________
Name and Address of Next of Kin
______________________________
______________________________
Emergency Contact No.
______________________________
Country of Origin: ____________________
Medical Information
Please 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
Cancer
Asthma
Eczema/Hay Fever
COPD (Chronic bronchitis)
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□No
□No
□No
□No
□No
□No
□No
□No
Please list the medications you are currently taking together with the dosage.
Are you registered disabled (if yes please give details)
□Yes
□No
Are you allergic to any medicines (if yes please give details)
□Yes
□No
Have you ever refused treatment/screening of any kind (if yes please give
details)
□Yes
□No
Other Details
Do you have a carer (if yes please give name, address and tel. no.)
□Yes
□No
Women
Have you ever had a cervical smear? (If yes, please give details of most recent
and where it was carried out)
□Yes
□No
Have you ever had a breast check and (If yes, please give details of most recent
and where it was carried out)
Do you smoke?
If No, have you ever smoked?
If Yes, how many cigarettes or ounces
of tobacco per week?
Would you like advice on giving up smoking
How much alcohol do you drink in a week?
(I unit= ½ pint beer, 1 small glass of wine, 1 single spirit)
What is your height?
___________________
What is your weight?
___________________
□Yes
□No
□Yes
□Yes
□No
□No
□Yes
□No
___________ units
Family History (first degree relatives i.e. parents, brothers, sisters)
Please state any serious illness, in particular heart disease, strokes, high blood
pressure, diabetes or any inherited disease. For example have you ever suffered
from any of the following. (Tick if appropriate)
Hypertension
Cardiovascular Disease
Asthma
Cancer
Colitis/Crohn’s
Underactive Thyroid
Rheumatoid Arthritis
Depression/Anxiety
Glaucoma
□
□
□
□
□
□
□
□
□
Ischaemic Heart Disease
Diabetes
COPD
Haemachromatosis
Abdominal Aortic Aneurysm
Epilepsy
Other (please specify below)
Phobia
□
□
□
□
□
□
□
□
Patients aged 60 and over or those with a chronic disease (eg asthma or
diabetes)
Have you ever had a flu vaccination (if yes give date of most recent)
□Yes
□No
Date_______________
Have you ever had a pneumococcal vaccination (if yes give date of most recent)
□Yes
□No
Date_______________
Signature: _______________________
Date: ________________
Please note that completion of this form does not guarantee acceptance to
the practice. Registration will only be completed following attendance at a
registration appointment and following receipt of medical notes from your
previous GP.