NEW PATIENT HEALTH QUESTIONNAIRE
Surname: ……………………………………………
First Names: …………………..…………………………………………
Address: ………………………………………………………………………………………………………………………………………….
Postcode: ……………………………………………
Tel. No.: …………………………………………………………..………
Mobile No.: …………………………………………
Date of Birth: …………………………..…………
Height: ……………….………. Weight: ……………….……………
Waist Measurement: …………….…..………..
Occupation: …………………………………..…………….…………..
Please state your ethnic origin:
Date of Entry Into Country (if applicable): ………………….……………….
First Language: ………………….………………….
White
British
Irish
Any other white background
Mixed
White and Black Caribbean
White and Black African
Any other mixed background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
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





Black or British Black
Caribbean
African
Any other black b/ground
Other
Chinese
Any other ethnic group









Smoking History (have you ever smoked, if so how much, if stopped when)
………………………………………………………………………………………………………………………………
Operations or Serious Illnesses
………………………………………………………………………………………………….
Family History of Diseases: (especially – Heart Disease, Blood Pressure, Chest Disease, Eye
Problems and Diabetes):
…………………………………………………………………………………..……………………………………………........
Are you on any regular medication from your last doctor or bought over the counter by yourself?
If so, what? .........................................................................................................................
Any Known Allergies: ……………………………………………………………….……………………………………….
Do you exercise regularly? ………………………….
Are you a carer?
YES / NO
Immunisations (for children only) – Please attach a copy of immunisations to date.
SMOKER?
NON SMOKER?
Please help us to bring your records up to date and complete the following:
If you are certain of the smoking status of other family members [age 14-90]
please complete a separate form for them.
Name: ……………………………………………
Date of Birth: ……………………………….…
NON SMOKERS
Never smoked
Ex trivial < 1/day
Ex light < 10/day
Ex moderate 10-20/day
Ex heavy 20-39/day
Ex very heavy >40/day
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SMOKERS
Trivial <1/day
Light 1-10/day
Moderate 10-20/day
Heavy 20-39/day
Very Heavy >40/day
Pipe smoker - number/day
Roll ups - ounces/day
]
]
PLEASE RETURN TO RECEPTIONIST
Tear off if desired
If you would like help trying to give up, please contact the Stop Smoking Service
on 0845 602 3608 or speak to one of our nursing staff.
New Patient Alcohol Questionnaire
Name: _______________________________________
DOB: ______________
QUESTION
1.Women: How often do you have 6 or more alcoholic drinks on the same
occasion?
Men: How often do you have 8 or more alcoholic drinks on the same
occasion?
2. In the last year, how often have you been unable to remember what
happened when you were drinking the night before?
3. In the last year, how often have you failed to do what was expected of you
due to drinking?
4. Has any one ever expressed concern about your drinking or advised you
to cut down?
SCORE
0
1
2
3
4
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Less than
monthly
Monthly
Weekly
Monthly
Weekly
Daily or
almost daily
Daily or
almost daily
Yes, during
the last year
Never
No
Yes, but not
in the last
year
Your
Score
If you scored 3 or more, please answer the following questions:
Question
5. How often do you have a drink that contains alcohol?
6. When you are drinking, on average how many standard alcoholic drinks do
you have?
7. In the last year, how often have you found yourself unable to stop drinking
once you have started?
8. In the last year, how often have you needed an alcoholic drink to get you
going in the morning?
9. In the last year, how often have you experienced guilt or regret after
drinking?
10. Have you or someone else ever been injured as a result of your drinking?
Total
Score
0
1
2
3
4
Never
Monthly or
less
3-4
2-4 times
per month
5-6
2-3 times
per week
7-8
4+ times per
week
10+
Less than
monthly
Less than
monthly
Less than
monthly
Monthly
Weekly
Monthly
Weekly
Monthly
Weekly
Daily, or
almost daily
Daily, or
almost daily
Daily, or
almost daily
Yes, in the
last year
1-2
Never
Never
Never
No
Yes, but
not in the
last year
Your
Score
E-MAIL SERVICE FOR PATIENTS
An email service is in place to provide better contact access for patients.
This is designed to be a non–urgent service. Urgent problems will still need to be
dealt with over the telephone.
Hopefully, this will reduce the need for telephone calls which will free receptionists’
time and will mean that patients will not need to wait to get through.
If you wish to use this service, the email address is:
Contacts.chiddingfold@nhs.net
Emails will be collected daily and responses will be actioned by the doctors and
receptionists.
Replies can be made by email if you wish. To access this part of the service, you
will need to sign a consent form allowing us to reply to a secure email address. If
this is not signed, the reply will be by telephone or letter.
Examples of email requests may be:
 Were my blood results normal?
 When does a doctor need to see me for a review?
 Was my X ray normal?
 Has my referral letter been sent?
 Have you had the letter from outpatients clinic yet?
 Are the results through from the hospital?
Please DO NOT email requests for appointments or ask for specific symptom
advice.
Prescription requests are available through our website: www.chiddsurg.co.uk
…………………………………………………………………………………………………………………………….
CONSENT FOR CHIDDINGFOLD SURGERY TO USE A SECURE E-MAIL ADDRESS
I …………………………………………….consent to the staff of Chiddingfold Surgery being able to
use the Email address below to contact me. I have informed them that this is a secure
Email address.
E mail address: ……………………………………………………………………………………….I am aware that
this email address will be entered onto my medical records but will not be passed to any
other person or persons and will not be used for any other purpose than the above.
Signed: …………………………………………………. Date: ……………………………………..
Witness: ……………………………………………….. Date: ..…………………………………
This practice has joined the national Summary Care Record programme which enables each patient
to have a summary of their key medical information held securely on the NHS central database, known
as the NHS Spine. This summary record could be used in an emergency if you needed treatment when
access to the medical record held by your GP was not available; for example if you call the doctor out
of hours. You will always be asked to give permission for this record to be viewed and you have the
right to decline.
Please indicate below whether you would like to have your own Summary Care record by indicating
your decision below. A full explanation of each choice follows.
1.
2.
3.
1.
My decision
I wish to have a Summary Care record containing my medications,
allergies and adverse reactions or sensitivities to medications
I wish to have a Summary Care record with the above plus
additional important medical information held on my record
I do not wish to have a Summary Care record
Tick ONE
A Summary Care record will be created for you from your the details held on our GP clinical
system and will contain:
a. any record we have of your current repeat medication, any acute medication (one-offs e.g.
antibiotics) and any recently discontinued medication
b. any record we have of adverse reactions to medication
c. any record we have of your allergies
2.
A Summary Care Record will be created for you containing the details itemised above in 1, PLUS
important additional information you and your GP agree would be useful. (e.g. Diagnoses Asthma, Diabetes etc.; Pacemaker, End of life care etc.) Please discuss this with your GP at your
next visit.
3.
A note will be made in your records that you do not wish to have a Summary Care Record. Please
note that if you attend A&E or if you need emergency treatment when the GP Practice is closed
the clinicians treating you may not have access to key information to help them give you the
most appropriate treatment.
Surname
First names
Signature
Date of birth
Today’s date
Hand this form to reception at your GP Practice.
For further information contact the Summary Care Record Information Line:
0300 123 3020