Office Use Only
Scan /
Other
MARPLE BRIDGE SURGERY – NEW PATIENT QUESTIONNAIRE
NAME:
____________________________
ADDRESS:
_________________________
___________________________________
POST CODE:
_______________________
OCCUPATION:
_____________________
DATE OF BIRTH:
________________________
HOME TEL. NO:
________________________
MOBILE NO:
____________________________
MARITAL STATUS:
TODAY’S DATE:
_____________________
________________________
EMAIL ADDRESS: _______________________________________________________________
Please circle answer
HAVE YOU EVER SUFFERED FROM ANY OF THE FOLLOWING?
Hypertension / High Blood Pressure
Angina / Heart Attack
Stroke
Diabetes
Asthma
Cancer
- If yes please state which type: _________________________________
HAVE YOU HAD ANY OTHER SERIOUS ILLNESS / OPERATIONS?
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
____________________
HAVE ANY OF YOUR CLOSE RELATIVES SUFFERED FROM ANY OF THE FOLLOWING?
(e.g. Mother, Father, Brother, Sister)
If yes, who and at what age?
Hypertension / High Blood Pressure
YES
NO
_______________________
Angina / Heart Attack
YES
NO
_______________________
Stroke
YES
NO
_______________________
Diabetes
YES
NO
_______________________
Asthma
YES
NO
_______________________
Cancer
YES
NO
_______________________
- If yes please state type: ______________________________
DO YOU TAKE ANY TABLETS OR MEDICINE REGULARLY?
YES
NO
YES
NO
WHEN DID YOU HAVE YOUR LAST SMEAR? _________________________
HAVE YOU EVER HAD AN ABNORMAL SMEAR
YES
NO
- If yes, what do you take? ______________________________________
ARE YOU ALLERGIC TO ANY TABLETS OR MEDICINE?
- If yes, what? ________________________________________________
WHAT IS YOUR HEIGHT? ________________________________________
WHAT IS YOUR WEIGHT? ________________________________________
WHEN WAS YOUR LAST TETANUS INJECTION? ____________________
FEMALES ONLY
DO YOU SMOKE?
- If yes, how many per day? ____________________________________
YES
NO
YES
NO
PLEASE BE AWARE THAT SMOKING CAN SERIOUSLY DAMAGE YOUR HEALTH.
SMOKING CESSATION CLINICS ARE AVAILABLE.
ARE YOU AN EX SMOKER?
- If yes, when did you stop? ____________________________________
FOR PATIENTS AGED 16 & OVER ONLY
MEN
WOMEN
Please circle score and add to give total
Please refer to the unit guide below
HOW OFTEN DO YOU HAVE 8 OR MORE UNITS ON ONE OCCASION?
HOW OFTEN DO YOU HAVE 6 OR MORE UNITS ON ONE OCCASION?
0 Never
3 Weekly
1 Less then monthly
4 Daily or almost daily
2 Monthly
HOW OFTEN DURING THE LAST YEAR HAVE YOU BEEN UNABLE TO REMEMBER WHAT
HAPPENED THE NIGHT BEFORE BECAUSE YOU HAD BEEN DRINKING?
0 Never
3 Weekly
1 Less then monthly
4 Daily or almost daily
2 Monthly
HOW OFTEN DURING THE LAST YEAR HAVE YOU FAILED TO DO WHAT WAS NORMALLY
EXPECTED OF YOU BECAUSE OF DRINKING?
0 Never
3 Weekly
1 Less then monthly
4 Daily or almost daily
2 Monthly
IN THE LAST YEAR, HAS A RELATIVE OR FRIEND, OR A DOCTOR OR OTHER HEALTH
WORKER BEEN CONCERNED ABOUT YOUR DRINKING OR SUGGESTED YOU CUT DOWN?
0 No
2 Yes
4 More than once
TOTAL ALCOHOL SCREENING SCORE:
____________
DO YOU CONSENT TO REFERRAL IF REQUIRED?
IS IT OK TO LEAVE AN ANSWER PHONE MESSAGE ABOUT THIS?
YES
YES
NO
NO
HOW MANY UNITS PER WEEK DO YOU DRINK? --------
WHAT IS SENSIBLE DRINKING?
MEN
No more that 3 to 4 units a day.
8 units or over is binge drinking.
WOMEN
No more than 2 to 3 units a day.
6 units or over is binge drinking.
In pregnancy, women are advised
not to drink at all.
ARE YOU A CARER?
- If yes, relationship to persons you care for: ________________________
YES
NO
MAIN SPOKEN LANGUAGE: _________________________________________
Central Government requires the Surgery to provide information about the ethnic origin of its patients. This
enables the Surgery to check the equality of the service. Please complete by ticking the box next to the
ethnic group to which you belong.
WHITE
British
Irish
Any other White background - please
give details: ______________________
BLACK OR
BLACK BRITISH
Caribbean
African
Any other Black background - please
give details: ______________________
ASIAN OR
ASIAN BRITISH
Indian
Pakistani
Bangladeshi
Any other Asian background - please
give details: ______________________
MIXED
White & Black Caribbean
White & Black African
White & Asian
Any other Mixed background - please
give details: ______________________
OTHER
Chinese
Do not wish to say
Any other ethnic background - please
give details:
______________________
Would you like to join our Patient Reference Group who we consult about our services from time to time
YES
NO
I agree that I may be contacted via email and/or SMS about practice news and advice about my health and
appointment reminders.
YES
NO
Please give name, address, telephone number and relationship of next of kin.
Details of prescriptions, medical conditions and any allergies will automatically be uploaded to the Stockport
Summary Care Record – to provide basic information on a needs basis to clinicians in Stockport unless you opt
out (please ask for information or see website). Please indicate that you understand this:
YES
Details of prescriptions, medical conditions and any allergies will automatically be uploaded to the National
Summary Care Record – to provide basic information on a needs basis to clinicians in unless you opt out
(please ask for information or see website). Please indicate that you understand this:
YES
Your personal and confidential data must, by law be allowed to be extracted by the Governments Health and
Social Care Information Centre unless you opt out (please ask for information or see website). Please indicate
that you understand this:
YES