COMBS FORD SURGERY

NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE

To the Patient:

Please complete this questionnaire as fully as possible and return with your registration forms to the receptionist. You will be contacted if any further information is required. If you have a complex medical history or are on regular medication you will need to make an appointment to see the doctor. This will need to be done in advance of repeat medication being required. All new patients may request a New Patient Check.

Surname: ………………………………………………….. Forename(s): …………………………

Date of Birth: …………………………………………….. Marital status: ….………………………

Address: …………………………………………………………………………………………………………….

……………………………………………………………….… Postcode: ………………………..….

Home tel: ……………………………………………..……

Mobile: ……………………………………….……………..

Work tel:…………………………………………………….

Occupation: ……………………………………………………………………………………………………….

Next of Kin (name/relationship)…………………………………………………………………………….

Next of Kin tel:……………………………………………

CARERS

Do you need / have anyone who looks after you or your daily needs as Carer? Yes / No

If “Yes”, would you like them to deal with your health affairs here? Yes / No

Name of carer and relationship…………………………………………………………………………………………

Carer tel:…………………………………………………..

Permission given to contact carer. Date………..

Do you care for anyone else registered at Combs Ford Surgery ? Yes / No

Name and relationship………………………………………………………………………………

SMOKING

Are you a current smoker? Yes / No

Are you an ex-smoker? Yes / No

Are you interested in stopping smoking? Yes / No

Would you like to receive smoking cessation

advice from this surgery? Yes / No

If yes, this can be discussed with the Nursing Assistant.

ALCOHOL SCREENING

How often do you have a drink containing alcohol?

Never (0.0)

Monthly or less (1.0)

Two to four times a month (2.0)

Two or three times a week (3.0)

Four or more times a week (4.0)

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

1 or 2 (0.0)

3 or 4 (1.0)

5 or 6 (2.0)

7 to 9 (3.0)

10 or more (4.0)

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

Never (0.0)

Less than monthly (1.0)

Monthly (2.0)

Weekly (3.0)

Daily or almost daily (4.0)

Weight (approx): ………………………………… Height ………………………………………

EXERCISE

Do you take regular exercise? Yes / No

If yes, what sort of exercise? …………………………………………………………………

How many times per week? …………………………………………………………………..

FAMILY HISTORY

Is there any of the following in your family (father, mother, brother, sister) before age of 60?

Heart Disease (heart attacks, angina) Yes / No Which family member? ………………………….

Stroke? Yes / No Which family member? ………………………….

Cancer? Yes / No Which family member? ………………………….

Site of cancer? ……………………………………

Other? ……………………………………………………………………………………………

MEDICATION

Please attach a repeat prescription form from your previous Surgery.

ALLERGIES

Are you allergic to any medications, substances or foods? Yes / No

If yes, please give details: ……………………………………………………………………………………………………….

PAST MEDICAL HISTORY

Please give details of any hospital treatment as an in-patient: ………………………………………………………………………………………………

Please give details of any treatment for any chronic medical conditions:

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

Please give dates of any X-ray, MRI or CT scans, Mammogram, Ultrasound:

………………………………………………………………………………………………

IMMUNISATIONS

Dates of Triple/polio/HIB: ……………………………………………………………………………………………..

Dates of MMR: ……………...……………………………………………………………………………………………..

Date of last Tetanus: …………………………………………………………………………………………………….

FEMALE PATIENTS

Date of most recent cervical smear: …………………………………..

Result of most recent smear: …………………………………………….

Please give details of any complications in pregnancy: ………………………………………………………………………………………………

Method of contraception used:

………………………………………………………………………………………………

Have you been advised of long acting reversible contraception i.e. coils, implants etc?

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

ETHNICITY

Please indicate your ethnic origin. It may be helpful to us to know this as some conditions are more common in specific communities, which could lead to early detection of some conditions. Please tick ONE box;

White / Tick / Mixed / Tick
British / White & black Caribbean
Irish / White & black African
Other / White & Asian
Other mixed
Asian or Asian British / Black or black British
Indian / Caribbean
Pakistani / African
Bangladeshi / Other black
Other Asian
Chinese or other ethnic group
Chinese
Any other
What is your first language?

Date of completion of this form: ………………………………………………………………………

Thank you for completing this questionnaire

Please Return To Reception..

M:\2013\Complaints and compliments\New_Patient_Health_Questionnaire 2012.doc- Updated 3 10 2013