New Patient Health Questionnaire - Milehouse Medical Practice

Your Contact Details

Title

Name

First

Last

Previous Surname

Occupation

Home Phone Number

Mobile Phone Number

Home Address

City

State/Province

Zip/Postal

Country

Email Address

Information About You

What is your height?

What is your weight?

What is your first language?

Do you need and interpreter?

Yes

No

Ethnic Group

White

British

Irish

Other

Black

Caribbean

African

Other

Asian

Indian

Pakistani

Chinese

Other

Mixed

White + Black Caribbean

White + Black African

White + Asian

Other

Previous GP

Name Of Previous GP

Address of Previous GP

City

State/Province

Zip/Postal

Country

Proof of Identity and Address Provided

Medical Information

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

Have you ever suffered from? (tick as appropriate)

Epilepsy

Yes

No

Blindness/Glaucoma

Yes

No

High Blood Pressure

Yes

No

Diabetes

Yes

No

Heart Attack/Stroke

Yes

No

Depression

Yes

No

Cancer

Yes

No

Asthma

Yes

No

Eczema/Hay Fever

Yes

No

COPD

Yes

No

If ‘yes’ please specify the condition in question and the year(s) when you were first diagnosed

Please list any medicines being taken and the amount

Are you registered disabled? (If yes, please provide details below)

Yes

No

Are you allergic to any medicines and if so, which? (provide details below)

Yes

No

Specify medication

Have you ever refused treatment/screening of any kind and if so, what and when? (provide details below)

Yes

No

Have you ever suffered from? (tick as appropriate)

Anxiety

Yes

No

Depression

Yes

No

OCD

Yes

No

Bipolar Disorder

Yes

No

If ‘yes’ please specify the condition in question and the year(s) when you were first diagnosed

Do you have any other mental health issues? (If ‘yes’, please give details)

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

Carers

Do you have a carer? (If ‘yes’, please provide details below)

Yes

No

Details

Are you a carer? (If yes please give details)

Option 1

Option 2

Details

Will

Do you hold a Living Will?

Yes

No

(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

Women

Have you ever had a cervical smear?(If ‘yes’, please state when, where and the result)

Yes

No

Cervical smear details (where/when/result)

Smoking

Do you smoke?

Yes

No

If ‘No’, have you ever smoked?

Yes

No

f you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes

No

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Family

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Next of Kin

Name

First

Last

Phone

Address

City

State/Province

Zip/Postal

Country

Add Remove

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 date or ‘never’

Contacting You

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Signature

Type out full name