HAVERFIELD SURGERY

CONFIDENTIAL PATIENT QUESTIONNAIRE

Name ______Date of Birth:______

Address:______

______Marital Status:______

______

Postcode:______

Telephone Nos: Home:______Preferred contact No. Home 

Mobile:______Mobile 

Work:______Work 

E-mail Address:______

Occupation:______

Weight:______Height:______

Next of Kin: ______Relationship______Tel No______

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Alcohol:

How often do you have a drink that contains alcohol?

Never Monthly/less 2-4 times per month 2-3 times per week 4+times per week

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

1-2 3-4 5-6 7-8 10+

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

Never less than monthly Monthly Weekly daily or almost daily

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Smoking Data: Never Smoked:

Current Smoker: If yes how many daily? ______

Ex-Smoker: 

Exercise Grading:ImpossibleAvoids Exercise

Light ExerciseModerate Exercise

Heavy Exercise

Drug Allergies: YES NO Name:…………………….………………

…………………………………………………………………………………………………. ………………………………………………………………………………………………….

Other Allergies: YES NO Name:…………………….………………

Bee Sting Allergy: YES  NO  Nut Allergy: YES  NO  Peanut Allergy: YES NO 

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Do you have any communication or information needs relating to a disability, impairment

or sensory loss? YES  NO 

Please let our Reception Team know so we can record your needs and provide you with information in alternative format.

SMS (text) messages: If you have supplied a mobile number you will automatically receive appointment reminders unless you say NO here: ______

In order to comply with the General Data Protection Regulation (GDPR)(EU) 2016/679 please see our Privacy Notice located in the waiting room, on our website or ask the Reception Team for a copy. The Notice explains your rights to privacy and how we gather, use and share information about you.

Carer Section

Are you a Carer? YES  NO 

Are you being cared for? YES  NO If yes please provide the details

Name of Carer:…………………………..…… Relative ……………………… Tel No……..…………………

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

Name of Primary Carer for child under 16:………………………….…

Tel No: ……………………… Address:………………………………….………………………………………..

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Ethnic classification: We are required to record the following information: please tick

WHITE: ASIAN or ASIAN BRITISH OTHER ETHNIC

British Indian Chinese

Irish Pakistan

Any other white Bangladesh

Background.

Any other Asian background

MIXED BLACK OR BLACK BRITISH

White & black Caribbean Caribbean

White & Black African African

White & Asian Any other Black Background

Any other mixed background

If you wish to decline this information, please tick here

Is English your first language? Yes No If no, please specify______

Religion:______

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Haverfield Surgery Virtual Patient Participation Group

If you would like to participate in this group, there are no meetings to attend. We will ask for your opinion or to answer a short questionnaire once a year for any suggestions on improving the surgery. Please tick YES here  We will need your email address, please write it here:

Email: ______

Your named accountable GP is Dr Ciobanu. This does not prevent you seeing any other doctor in the practice as your records are available to every doctor in the surgery.

Please tick here that you have read this statement

Haverfield Surgery are able to offer patients the Electronic Prescription Service(EPS). This is an NHS service that sends your prescription electronically from GP Surgery to your chosen “nominated” pharmacy which could be near to where you live, work or shop. If you are interested in using EPS please contact the pharmacy of your choice and they will be able to process your “nomination” request.

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