TOPCLIFFE SURGERY NEW PATIENT QUESTIONNAIRE
Please help us to help you!
If you are on any medication, have any of the problems
listed below or other health concerns, then please make an appointment to see the doctor.
Name__________________________________________Date of Birth________________
Do you have any of the following?
YES
Heart disease, Heart Attack or Stroke
High Blood Pressure
Diabetes
Chronic pulmonary obstructive disease
Asthma
Eczema or Hay fever
Other (please specify)
NO
YES
NO
Arthritis
Epilepsy
Thyroid condition
Mental health problem
Cancer
Inflammatory bowel disease
Are you on any medication?
YES/ NO
If you are on medication, please make an appointment to see the doctor with a list of your current
treatment before you need some more.
Are you allergic to any thing including medication?
YES/ NO
What are you allergic to?______________________________________________________
Are you a carer?
YES/ NO
Do you have a carer?
Do you have a living will?
YES/ NO
YES/ NO (if yes, please may we have a copy?)
Family history?
Does your parent, brother, sister or child have any problem such as: breast,
ovarian or bowel cancer, osteoporosis, heart disease or strokes, diabetes, high blood pressure or
cholesterol? If so, please fill in the table below
Relation
Disease
Ethnicity
Age at onset
Details
please circle the ethnic group with which you most closely identify
White
British
Irish
Mixed
White & Asian
Asian or Asian British
White & Black
Caribbean
Indian
Black or Black British
Caribbean
African
Chinese or Other
Chinese
Other
Bangladeshi
Please turn over!
White & Black
African
Pakistani
Height________________________
Weight__________________________
Smoking
Ever smoked
YES/ NO
Current smoker
YES/ NO
How many per day?_____________how many years have you smoked?______________
Ex-smoker
YES/ NO
How many per day?_____________how many years did you smoke?______________
We strongly advise everyone to stop smoking. If you would like help to stop, please make an
appointment for the nurse
Alcohol
How many units do you drink most weeks? (See below)__________________________
This is one unit of alcohol…
…and each of these is more than one unit
Complete these three questions to see if you may be at risk from your drinking
Scoring system
Questions
0
1
2
3
4
How often do you have a drink containing alcohol?
Never
Monthly
or less
2-4
times
per
month
2-3
times
per
week
4+
times
per
week
How many units of alcohol do you drink on a typical
day when you are drinking?
1 -2
3-4
5-6
7-9
10+
How often have you had 6 or more units if female, or
8 or more if male, on a single occasion in the last
year?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
Your
score
TOTAL SCORE
_____
A total score of 5 or more may indicate that your drinking may be harmful to your health. Please
see the doctor or nurse to discuss this further