46 St Isan Road
Heath
Cardiff
CF14 4UU
029 2062 7518
029 2052 2866
DR. P HYWEL SMITH MB BCH MRCGP
DR. NOEL P T MCLOUGHLIN MB BCH MRCGP
DR. MELANIE J M BAGSHAW MB BS MRCGP
DR. BETHAN V BROOKS MB BCh MRCGP
ST ISAN ROAD SURGERY
NEW PATIENT HEALTH QUESTIONNAIRE
Personal Details
Title:
Surname:
DOB:
Forename(s):
Gender:
Contact
Details:
Address:
M
F
Home:
Work:
Mob:
Email:
Others in household:
Name(s):
Age(s):
Relationship:
Are you a carer for someone who is ill,
frail, disabled or mentally ill?
YES
NO
*YES
NO
Are you cared for by someone?
*Please provide carers details?
Name:
Relationship:
Telephone
Number:
Please turn over……….
46 St Isan Road
Heath
Cardiff
CF14 4UU
029 2062 7518
029 2052 2866
DR. P HYWEL SMITH MB BCH MRCGP
DR. NOEL P T MCLOUGHLIN MB BCH MRCGP
DR. MELANIE J M BAGSHAW MB BS MRCGP
DR. BETHAN V BROOKS MB BCh MRCGP
ST ISAN ROAD SURGERY
Medical History
Have you ever suffered from
any of the following
illnesses?
Diabetes
YES
NO
Heart Disease
YES
NO
Stroke
YES
NO
High Blood Presssure
YES
NO
Epilepsy
YES
NO
Kidney Disease
YES
NO
Asthma/Chronic Lung
Disease
YES
NO
Other serious Illness
YES
NO
Please specify……
Have you ever had any
operations?
YES
NO
Are you on any repeat
medication?
YES
NO
General Information
Do you smoke?
YES
NO
If yes how many
per day?
Do you drink
alcohol?
YES
NO
How much per
week?
Women Only
When was the date of your last smear?