NEW PATIENT HEALTH QUESTIONNAIRE
Title:
Date of Birth:
Marital Status:
Occupation:
Mobile No:
Home Address:
Surname:
Previous Surnames:
Forenames:
Home Telephone:
Email:
Next of Kin Details:
Name:
Relationship:
Contact Details:
Information About You
What is your height?______________________________________
What is your weight? _____________________________________
What is your first language? ________________________________
Ethnic Group: (Please circle)
White
Black
Asian
British
Caribbean
Indian
Irish
African
Pakistani
Other
Other
Chinese
Other
Have you ever suffered from any of following? (Please circle)
Condition
High Blood Pressure
Heart Disease
Atrial Fibrillation
Stroke/TIA
Arterial Disease
Diabetes
Cancer
Condition
Asthma
Chronic Lung Disease
Depression/Anxiety
Eating Disorder
Dementia
Other Mental Health Problems
Thyroid Disease
Condition
Epilepsy
Migraine
Osteoporosis
Coeliac Disease
Arthritis
Chronic Kidney Disease
HIV
Learning Disability
Registered Disabled
Blindness/Glaucoma
Do you have any allergies? (If yes please specify)
Please list any medication you are taking: (include inhalers, creams, contraceptive
pills,etc)
Have you been immunised against the following? Please circle and put date if known)
Vaccination
Diphtheria (All three plus booster)
Tetanus (All three plus booster)
Polio (All three plus booster)
Pertussis (All three plus booster)
Haemophilus B (All three plus booster)
MMR (Measles/Mumps/Rubella – x2)
HPV (Cervical Cancer Injection – x3)
Meningitis C (All three plus booster)
Pneumococcal (All three plus booster)
Typhoid (All three plus booster)
Hep A (All three plus booster)
Hep B (All three plus booster)
Yellow Fever (All three plus booster)
Any Others
Date
Are you Armed Forces Reservist or a Military Veteran? (Please Circle) Yes
No
Lifestyle
Do you take regular exercise? _________________________________________
How many times a week do you exercise? _______________________________
What sort of exercise do you do? ______________________________________
Do you keep to a special diet? _________________________________________
Do you add salt to your food after cooking? ______________________________
Has your cholesterol been checked in the last 2 years? ______________________
Are you a carer for someone? Yes/ No
Do you have a carer? Yes/ No. If Yes please provide name and contact details: _________
________________________________________________________
Smoking
The Practice offers smoking cessation advice, please ring the surgery to arrange an
appointment for advice if you which to quit.
Smoking
Do you smoke?
If yes, how many:
How old were you when you started smoking?
If you are an ex-smoker when did you quit?
Are you exposed to smoke at work?
Are you exposed to smoke at home?
Please circle, and provide details
Yes/ No
Cigarettes per day:
Cigars per day:
Ounces of tobacco per day:
Date quit:
Yes/ No
Yes/ No
Alcohol
Please fill out the following table. Please circle the answer that best applies – 1 drink = ½
pint of beer, one glass of wine or 1 single spirit.
0 = Never, 1 = Monthly or Less, 2 = 2-4 times per month, 3 = 2-3 times per week, 4 = 4 +
times per week
Questions
How often do you have an alcoholic drink?
How many units of alcohol, do you have on a typical day, when you
are drinking?
How often do you have 6 (for women) or 8 (for men) or more units
of alcohol on one occasion?
How often during the last year have you been unable to remember
what happened the night before because of your drinking?
How often during the last year have you failed to do what normally
expected of you because of your drinking?
Score
Your Score
In the last year has a relative or friend, or a doctor or other health worked been concerned
about your drinking or suggested you cut down? (Please circle)
No never
Yes on one occasion Yes on more than one occasion
Family History
Please give details of any illnesses which run in your family or affect your immediate family
(parents, brothers, sisters, grandparents or your children).
Please include Heart Disease, Thrombosis (DVT/PE), Breast, Ovarian, Colon, Prostate,
Melanoma (Skin) Cancer, Any other cancers, Thalassaemia or Sickle Cell, Coeliac Disease,
Osteoporosis, Serious Mental Health Illnesses or any other you feel relevant.
Disease/Illness
Which relative affected?
Date
FOR WOMEN
If you have had a cervical cytology test (“Pap” smear), please tell us:
Date of last smear: ________________________________________
Was it normal? Yes/ No
When is your next smear due? ________________________________________________
What method (or brand) of birth control (contraception) do you use? _________________
How many pregnancies have you had? ___________________________________________
What happened in each pregnancy (e.g caesarian, miscarriage, termination)? Please include
dates: _____________________________________________________________________
Have you had a hysterectomy (womb removed)? Yes/ No.
If Yes, date _________________________________________________________________