LAMMERMUIR MEDICAL PRACTICE
NEW PATIENT HEALTH QUESTIONNAIRE
Welcome to Lammermuir Medical Practice. As it takes time for your
records to be transferred from your previous GP we would appreciate if
you to fill out the attached questionnaire. Don’t worry if you cannot
remember exact dates or details. Thank you for you co-operation.
PERSONAL DETAILS
Name ______________________________________________________
Date of Birth______/_______/_______
Home Address_______________________________________________
___________________________________________________________
___________________________________________________________
_______________________________________ Postcode____________
Home telephone number_____________________
Day time contact telephone number (mobile or work)________________
Marital Status________________________________________________
(single/married/divorced/live with partner or widow/widower)
Who lives at home with you?___________________________________
___________________________________________________________
___________________________________________________________
(e.g. wife, husband, children, parents)
Are you a Carer for any of your family members?
___________________________________________________________
___________________________________________________________
Occupation__________________________________________________
Next of kin:
Name___________________________Relationship_________________
Tel number__________________________________________________
MEDICAL HISTORY
When did you last attend your previous GP surgery?_________________
What for?___________________________________________________
___________________________________________________________
___________________________________________________________
________________________________________________
Have you been attending your previous GP surgery on a regular basis for
anything? If yes, please give details______________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Are you currently seeing, or waiting to see, a hospital specialist for
anything ? If yes, please give details._____________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Have you had any serious illnesses or operations?___________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Have you been in hospital for anything else not already mentioned?
___________________________________________________________
___________________________________________________________
FAMILY HISTORY
Do any illnesses run in your family? _____________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
We are specifically interested in high blood pressure, heart disease,
stroke, diabetes, asthma and cancer. If any first-degree relatives (mother,
father, sister, brother) have died before age 60 please give details.
MEDICATION
Are you taking any regular medication? Please list all prescription drugs
and also any drugs you buy from the chemist on a regular basis.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
ALLERGIES
Do you have any allergies, drug or food intolerances? If yes, please list
what you are allergic/intolerant to and what kind of reaction you
experienced. ________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
IMMUNISATIONS
Please list details of any immunisations you have received, if known.
Specifically, do you know if you have had a complete course of tetanus or
when you last had a tetanus booster? _____________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
For children under 16 please list childhood immunisations; for children
under 5 please bring their Parent held Child Health Record when they are
seen. ______________________________________________________
___________________________________________________________
___________________________________________________________
HEALTH SCREENING (only complete if applicable)
When did you last have a cervical smear? _________________________
Was it a normal result? ________________________________________
Have you ever had abnormal cervical smears? If yes, please give details.
_____________________________________________________
Have you had breast screening (mammogram)? If yes, please give details.
___________________________________________________________
LIFESTYLE
Do you smoke? If yes, please give details (e.g. cigarettes, pipe, tobacco)
and amount._________________________________________________
Have you ever smoked? If yes, how long for, how much and when did
you give up? ________________________________________________
Would you be interested in receiving advice about stopping smoking?
Yes____
No____
Do you drink alcohol? If yes, how many units would you estimate per
week? 1 unit = 1 measure of spirits or 1 glass of wine or half pint of beer
___________________________________________________________
Do you take any regular exercise? Please give details.________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Interpreter required? Yes___ No___
Preferred language spoken __________
ANY OTHER RELEVANT INFORMATION
We aim to provide the best medical services to our patients. Is there any
other information you think we should know about not covered in the
questionnaire? _______________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
COMPLETED BY __________________________________________
(please state relationship to patient if not completed by patient)
SIGNATURE_______________________________________________
DATE___________________________
All information given is confidential under the Data Protection Act