New Patient Health Questionnaire

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SEVERN VALLEY MEDICAL PRACTICE

New Patient Health Questionnaire

Patient Details

Title

Date of Birth

Occupation

Mr Mrs Miss Ms Surname

First Names

Previous Surnames

Home Address:

Post Code:

Tel No: Mobile:

Name and Address of Previous GP:

Ethnic Group

White

Black

Asian

British

Irish

Other (Please specify)

Caribbean

African

Other (Please specify)

Indian

Pakistani

Chinese

Other (Please specify)

Work:

Mixed

Language

White & Black Caribbean

White & Black African

White & Asian

Other (Please specify)

What is your first language?

Proof of Identity

Birth Certificate

Allowance Book

Driving Licence

Solicitor’s Letter

Passport

Offer of Tenancy

Please list any medications being taken and the dosages:

Utility Bill

Other

Are you registered disabled? Yes No

If yes please give details of your disability: ……………………………………………………………………………

………………………………………………………………………………………………………………………………

Medical Information

Please list any serious illnesses/operations/accidents/disabilities (and for women, pregnancy related problems) and the year they took place.

Have you ever suffered from? (tick as appropriate)

Epilepsy

High Blood Pressure

Heart Attack/Stroke

Yes

Yes

Yes

No

No

No

Cancer

Eczema/Hay Fever

Yes

Yes

No

No

Are you allergic to any medicines and if so, which ?

Blindness/Glaucoma

Diabetes

Depression

Asthma

Yes No

Yes No Have you ever refused treatment/screening of any kind, and if so what?

Women

Yes

Yes

Yes

Yes

No

No

No

No

Have you ever had a cervical smear? Yes No

If yes please state when and where: ………..…………………………………………………………………………

………………………………………………………………………………………………………………………………

Do you smoke?

If no, have you ever smoked?

Yes

Yes

No

No

If yes how many cigarettes or ounces of tobacco per week? ………………………………………………………

Yes No Would you like advice on giving up smoking?

How much alcohol do you drink in a week? units

(1 unit = ½ pint beer, 1 small glass of wine, 1 single spirit, 1 small glass of sherry or 1 single aperitif)

OVER 16’s ONLY

Alcohol Users Disorders Identification Test (AUDIT) C

Questions

0

Never

1

Monthly or less

Scoring System

2

2-3 times per month

3

2-3 times per week

4

4+ per week

Your

Score

How often do you have a drink that contains alcohol?

How many standard alcoholic drinks do you have on a typical day when you are drinking?

How often do you have 6 or more standard drinks on one occasion?

Your height:

1-2

Never

3-4

Less than monthly

5-6

Monthly

Your weight:

7-8

Weekly

10+

Daily or almost daily

Family History

Please state any serious illness, in particular heart disease, strokes, high blood pressure, diabetes or any inherited disease:

………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………….

For Patients aged 65 and over

Please give name, address and telephone number of next of kin:

………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………….

For Patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or ‘never’

Have you had a pneumococcal vaccination? Enter a date or ‘never’

Other information

Do you have a carer? Yes No

If yes please give details of your carer:

………..…………………………………………………………………………..

………………………………………………………………………………………………………………………………….

Are you a carer? Yes No

If yes please give details of who you care for:

..…………………………………………………………………………..

………………………………………………………………………………………………………………………………….

Do you hold a living will?

Signature:

Yes No

(Documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

Date:

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