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?