NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE
Welcome to Wolverton Health Centre.
To register with the Practice please complete this questionnaire as fully as possible.
The information will help the doctor to make an initial assessment of your health
Which will help in your future treatment and enable us to provide you with good
Medical care.
Surname: ……………………………………………….. Forename(s): …………………………………
Date of Birth: ………………………………………….. Marital status: ….……………………………
Address: ………………………………………………………………………………………………………….
…………………………………………………………….… Postcode: …………………………………..….
Home tel: …………………………………………..…… Mobile: ……………………………………….…
Email address: …………………………………………………………………………………………………
Occupation: …………………………………………………………………………………………………….
Weight (approx): …………………………………….. Height: …………………………………………
Date of completion of this form: ……………………………………………………………………….
SMOKING
Do you smoke?
Yes / No
If Yes, how many:
Cigarettes per day …….. Cigars per day ..….. Ounces of tobacco per day ……..
How old were you when you started smoking? …………………..
EX-SMOKERS
How old were you when you stopped smoking? …………………
How much did you smoke per day? …………………………………..
If you are a smoker can I take this opportunity to advise you regarding the health
risk of smoking and ask if you would like smoking cessation advice ? Yes / No
ALCOHOL
How many units of alcohol do you drink per week?
(1 unit = half pint of beer, 1 glass of wine, or a
pub measure of spirits)
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have
on a typical day when you are drinking?
How often do you have six or more drinks on one
occasion:
EXERCISE
Do you take regular exercise?
None
1 to 5 units per week
6 to 10 units per week
11 to 15 units per week
15 or more per week
Never
Monthly or less
2 to 4 times a MONTH
2 to 3 times a WEEK
4 or more times a week
1 or 2 drinks
3 or 4 drinks
5 or 6 drinks
7 or 8 or 9 drinks
10 or more drinks
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Yes / No
If yes, what sort of exercise? …………………………………………………………………
How many times per week? …………………………………………………………………..
DIET
Do you follow a particular diet?
Yes / No
If yes, which type? ………………………………………………………………………………
Has your cholesterol been checked in the last 2 years
Yes / No
MEDICATION
Please give details of any medication which you take (prescribed or otherwise):
Name of drug: …………………………………………………
Dosage: ………………………………………………………….
Name of drug: …………………………………………………
Dosage: ………………………………………………………….
Name of drug: …………………………………………………
Dosage: ………………………………………………………….
FAMILY HISTORY
Have any members of your family ie father, mother, brother, sister suffered from
any of list below before the age of 65?
Heart Disease (heart attacks, angina)
Yes / No Which family member? …………….
Stroke?
Yes / No Which family member? …………….
Cancer?
Yes / No Which family member? …………….
Site of cancer? ………………………………………
MEDICATION
Please give details of any medication which you take (prescribed or otherwise):
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
ALLERGIES
Are you allergic to any substances or foods?
Yes / No
If yes, please give details:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
IMMUNISATIONS
Dates of Triple / polio / HIB: ……………………………………
Dates of MMR: …………………………………………..
Date of last Tetanus: ………………………………….
FEMALE PATIENTS
Date of most recent cervical smear: …………………………………………………….
Result of most recent smear: ………………………………………………………………
Please give details of any complications in pregnancy:
…………………………………………………………………………………………………………………………
PAST MEDICAL HISTORY
Please give details of any hospital treatment as an in-patient:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Please give details of any treatment for any chronic medical conditions:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Please give dates of any X-ray, MRI or CT scans, Mammogram, Ultrasounds:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
CARERS
Do you need / have anyone who looks after you or your daily needs
as Carer?
If “Yes”, would you like them to deal with your health affairs here?
(the receptionist can help with these arrangements)
Yes / No
Yes / No
Contact Number for your Carer: …………………………………………………………………………
Do you care for anyone else?
Yes / No
NEXT OF KIN
Name …………………………………………………………Relationship to you……………………..
Address: ………………………………………………………………………………………………………..
Telephone no. / contact details: ……………………………………………………………………….
Thank you for completing this questionnaire.
For office use only:
Registration taken by: ……………………………………………….
ID Supplied:
Passport
Proof of residence supplied
[ ]
Driver Licence [ ]
Other ………………………..
Yes / No
Document scanned to clinical system: …………………………….Registration approval date: ………….............