Enys Road Surgery

New Patient Questionnaire

The Doctors and staff welcome you to the practice, in order for us to provide you with good quality care; it would be helpful if you could complete the questionnaire below to provide us with some information regarding your personal details and your medical history.

Surname / First Name
Date of Birth / Sex
Address / Tel. no. Home
Work
Postcode / Mobile
e-mail
Next of Kin / Address & Tel.
Relationship

Your Ethnic Group (circle where appropriate)

White British / White Irish / White other / Mixed white and black Caribbean / Mixed white and Black African
White and Asian / Other mixed background / Indian / Pakistani / Bangladeshi
Other Asian background / Caribbean / African / Other Black background / Chinese
Other

Your Medical History

Do you have any of the following illnesses? (Circle if appropriate)
Diabetes / Asthma / COPD/Emphysema / Epilepsy / Hypothyroidism
Stroke/TIA / Heart Disease / High Blood Pressure / Kidney Disease / Cancer
Mental Illness / Depression / Heart Failure
Please list other illnesses/operations that you have had or have (with dates).
Are you allergic to anything? (e.g. medication, sticking plasters, bee stings, eggs etc)

Medication

What medication do you take?
A repeat prescription counterfoil from your previous GP would be useful, please attach if you have one.

Family History

Is there any of the following in your immediate family (Parents/Grandparents/uncles/Aunts/Brothers/sisters)
Heart Disease (heart attack, angina) / Y/N / Which family
member?
Stroke / Y/N / Which family
member?
High Blood pressure / Y/N / Which family
member?
Diabetes / Y/N / Which family
member?
Cancer / Y/N / Which family
member?
Other / Y/N

Lifestyle

Do you smoke? / Y/N / How many a day?
Have you ever smoked? / Y/N / When did you stop?
Do you drink? / Y/N / How many units a week?
1 unit = small glass of wine = half a pint of beer/lager = 1 pub measure of spirit.
Do you exercise regularly during the week? / Y/N / How many times?
Do you eat a balanced diet? Y/N / Do you need to lose weight? Y/N / Do you add salt to your food? Y/N

Female Patients only

What form of contraception do you use?(circle please)Pill/condoms/coil/injections/sterilised/other/not sexually active
Have you had a cervical smear test in the last 3/5 years?
(25-64yrs) Y/N / Date
Result
Where did you have it done?
Have you had a hysterectomy? Do you still have a cervix? / Y/N / Date
Dates of pregnancies (full term if any)
Dates of miscarriages (if any)
Dates of terminations (if any)
Date of last breast screening (aged between 50-70yrs)