West End Surgery – Patient Health Questionnaire
Dear Patient
This letter invites you, as a newly registered patient, to have a Health Check. This involves answering
some questions and carrying out a simple examination. This service is offered to all our newly registered
patients over the age of five years. It would be helpful to your doctor if you could complete as much of
this form as possible before you are seen.
Surname:……………………………………..
Forenames: ……………………….……………..
Address: ……………………………………………………………………………………………..………...
Post Code: …………………………………..
Tel. No: ……………………………..…………….
Date of Birth: ………………………………...
Height: …………….
Weight: ……..…….…….
Status: Single / Married/ Separated / Divorced / Widowed / Other (please circle0
Occupation: ………………………………………………………………………..…………………………
Next of Kin details: ……………………………….. …………………….
Are you a carer? Yes \ No
What serious illnesses have you had? …………………………………………………………..….……..
…………………………………………………………………………………………………………..……………
What operations have you had? (please include year) ………………………………………..…………
…………………………………………………………………………………………………..………………
Hospital care – are you under hospital care? YES / NO
If ‘yes’ which hospital?…………………………………………………………………………..……………
Which department? ………………………….
Which doctor? …………………..……………….
Do you have any medical problems at the moment? ……………………………………….……………
…………………………………………………………………………………………………………..………
Please list any allergies you have: …………………………………………………………………..……..
MEDICATION - Please list any tablets, medicines or other treatment you are taking (including those
bought from a chemist)
………………………………………………………………………………………………...……...
……………………………………………………………………………………………………………….….
……………………………………………………………………………………………..…………………………
If you are on repeat medication, you will need to bring in either your repeat slip from your
previous doctor or, if you do not have this, we will need to see original boxes, bottles etc.
Have you ever suffered from, or been treated for, any of the following: (please tick)
Asthma, bronchitis or frequent chest infections …………………………………….…………………….
Cancer …………………………………………
Depression or mental illness ……..…………….
High cholesterol or fat in the blood …………
Epilepsy ……………………..……………………
Heart problems ……………………………….
Stroke ……………………..……………………...
High blood pressure ………………………….
Diabetes ………………………………………….
FAMILY HISTORY – Have any of your immediate family (parents, brother or sister) suffered from the
above? If yes, please state what relationship and what they have suffered from:
Mother, Father, Brother, Sister …………………………………………………………..………………….
Which IMMUNISATIONS have you had and when? (please tick)
Diphtheria ……………
Measles …………..
Measles / Mumps/ Rubella ……..………
Tetanus ………………
Pertussis (whooping cough) …………
Rubella (German measles) …………………….
Polio ……………………..
Other ……………………………..……….
SMOKING STATUS: Are you a… (please complete one answer)

Current Smoker? Yes \ No
If yes, how many do you smoke per day? ……….
Would you like help to stop smoking? Yes / No

Ex-Smoker? Yes \ No

Never Smoked? Yes \ No
If yes, when did you stop smoking? …………………
ALCOHOL - For the following questions, please circle the answer which best applies.
1 drink = ½ pint beer, 1 glass of wine or 1 single spirit
Men: How often do you have EIGHT or more drinks on one occasion?
Women: How often do you have SIX or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How many alcoholic drinks do you have in a typical week? …………
What sort of EXERCISE do you take? …………………………………………..…………………………
How many hours of exercise do you take on average each week, which makes increases your breathing
rate? …………. hours.
WOMEN ONLY –
When did you last have a breast scan? …………………….……………………
When did you last have a cervical smear? ………..……………….…..………..
Was it taken by your GP or other (please specify)? …...………………..………
I wish / do not wish to accept the offer of a physical examination. It is the responsibility of the patient to
make the appointment. (Please delete as applicable.)
Date form completed …………………….
IDENTIFICATION DOCUMENTATION –
Date seen …………………………………….
1 ……………………………………………….
2 …………………………………………………………....