Woodley Village Surgery

NEWPATIENT QUESTIONNAIREStockport

WelcometoWoodley Village Surgery

Toregister withthispractice, please completethisquestionnaire asfullyas possible.ThequestionshavebeendesignedtohelpyournewGPgettoknowyouand yourmedicalhistorywhilst yourmedicalrecordsarebeingtransferredtous.Theinformationyougive willhelpustoprovideyouwithgood medical care.

For those patients taking regular prescribed medicines, please ensure you have 1 months’ supply from your existing GP before you register - you will need to book a face to face appointment with your new GP within 3 weeks of registering before your repeat medications can be issued (Please bring a copy of your repeat slip and boxes of medication to your appointment)

PLEASEALSOCOMPLETETHE PURPLE NHS REGISTRATION FORMPERSONALDETAILS:

Areyouacarer?-Doyouprovidecareforsomeonebecauseoftheirpoorhealthordisability?Pleasetellusthenameandcontactdetailsofthepersonyoulookafterandtheirrelationshiptoyou.
Areyoucaredfor?- Doyouneedsomeonetocareforyoubecauseofyourpoorhealthordisability?Pleasetellusthenameandcontactdetailsofthepersonwholooksafteryouandtheirrelationshiptoyou.
Areyouregistereddisabled? / YESNO
Areyouhousebound? / YESNO
WouldyouliketojoinourvirtualPatientParticipationGroup? / YES NO
Pleaselistyourmedicationorattachacopyofyourprescription
SummaryCareRecord / SummaryCareRecordsprovidehealthcarestafftreatingpatientsinanemergencyorout-of-hourswithfasteraccesstokeyclinicalinformation.Ifyouarehappyforyour
informationtobeusedinthiswayyoudonothavetodoanything.IfyouwishtopreventthisfromhappeningpleaseaskatreceptionforaSummary CareRecordOptOutform.

HEALTHQUESTIONS:

Doyouhaveanyallergies? / YES / NOIfyes,pleasestate ………………………………………………..…..
Doyousmoke? / YESNO / Ifyes,howmanycigarettesaday?………………………………………………..………EX-SMOKER
Wouldyoulikesupporttostopsmoking? / YES / NO
Howmuchdoyouweigh?
Howtallareyou?
Whatisyourbloodpressure?
Doyousufferfromanyofthefollowing? / ASTHMACOPDCANCER / STROKEHEARTDISEASEMENTALHEALTH
DIABETESSTROKEDEPRESSIONEPILEPSYHIGHBLOODPRESSUREOTHER
Istherefamilyhistoryofanyoftheconditionsmentionedabove?Ifyes,pleaseprovidesomedetails

HEALTHQUESTIONS(continued):

Alcoholconsumption / Thisisoneunitofalcohol:

Howoftenhaveyouhad6ormoreunitsiffemale,or8or moreifmale,onasingleoccasioninthelastyear? / NEVER(0)WEEKLY(3)
LESSTHANMONTHLY(1)DAILY/ALMOSTDAILY(4)
MONTHLY(2)
OnlyanswerthefollowingquestionsiftheansweraboveisNever,LessthanmonthlyorMonthly.
StophereiftheanswerisWeeklyorDaily.
Howoftenduringthelastyearhaveyoufailedtodowhatwasnormallyexpectedfromyoubecauseofyourdrinking? / NEVER(0)WEEKLY(3)
LESSTHANMONTHLY(1)DAILY/ALMOSTDAILY(4)
MONTHLY(2)
Howoftenduringthelastyearhaveyoubeenunabletorememberwhathappenedthenightbeforebecauseyouhadbeendrinking? / NEVER(0)WEEKLY(3)
LESSTHANMONTHLY(1)DAILY/ALMOSTDAILY(4)
MONTHLY(2)
Hasarelativeorfriend,doctororotherhealthworkerbeenconcernedaboutyourdrinkingorsuggestedthatyoucutdown? / NEVER(0)WEEKLY(3)
LESSTHANMONTHLY(1)DAILY/ALMOSTDAILY(4)
MONTHLY(2)

FEMALEPATIENTSONLY:

Areyoucurrentlypregnant? / YES / NO
Resultofyourlastsmear? / Normal / Abnormal
Pleaseprovidedetailsofyourcurrentcontraceptivemethod(ifany)