Blessing Medical Centre

PATIENT HEALTH QUESTIONNAIRE

Name (please PRINT) ______

Date of Birth______Male [ ]Female[ ]

Please state your country of origin______Married[ ]Single[ ]

Maiden Name______

Are you in full time/part time study?YES [ ] NO [ ]

Are you unemployed?YES [ ] NO [ ]

Employed? Occupation______Full time [ ]Part time [ ]

First Language ______

Email Address…………….……………………………

Section A. General Information

  1. Do you need support with spoken English? YES [ ] NO [ ]

[ ] Interpreter needed please state which language/dialect [ ]

NB: interpreters can be booked NO SOONER than 48hrs from request

  1. Please give details of your housing status: Bed & Breakfast [ ] Hotel [ ] Private rent [ ]

Council [ ] Sheltered housing [ ] Hostel [ ] Residential [ ] Owner occupier [ ]

Other, please state______

Are you a refugee or are you seeking political asylum in the UK? YES [ ] NO [ ]

Section B. Health information

  1. Do you smoke NO [ ] YES[ ] If Yes, how many cigarettes do you smoke per [ ]

If NO, Never smoked [ ] Ex-smoker [ ]Date/Year stopped [ ]

  1. Do you have any allergies? NO [ ] YES, please state______
  1. Names and dates of any minor/ serious illnesses/ailments or operations______

______

  1. What, if any, medicines are you taking? ______

Are you allergic to any medication? ______

  1. Do YOU suffer from any of these illnesses? Heart Attack[ ] Diabetes [ ] Asthma [ ]

Stroke [ ]Cancer [ ] Tuberculosis[ ]High Blood Pressure [ ]Angina [ ]

Mental illness[ ] Epilepsy [ ] Sickle Cell [ ] Other______

Family History: Which, if any, of your blood relations (father, mother, brother, sister) suffered from the following:Stroke [ ] Cancer [ ] High Blood Pressure [ ] Angina [ ]

Mental illness [ ] Epilepsy [ ] Sickle Cell [ ] Other______

  1. Please give dates of vaccinations you have had in the past 10 years. Please include childhood and travel immunisations:

______Date______

______Date______

______Date______

When was your the last tetanus injection (Year)?[ ]

  1. For FEMALE patients ONLY

Have you had any children? ______Please give ages______

Have you had a hysterectomy?______Please give date______

When, where and what was your last smear test?______

Which method of contraception are you using at present?______

Please tick the box if you DO NOT require contraceptive services

Section C. About your ethnic group

  1. To which of these ethnic groups do YOU feel YOU belong to? Please tick ONE box

White[ ]Black [ ]Irish[ ]

White British [ ]Black British[ ]

White European [ ]Caribbean [ ]

African[ ]

ASIAN [ ]Other Ethnic Group

Indian[ ]Chinese [ ]Vietnamese[ ] North African Arab/Iranian [ ]

Pakistani[ ]Arab[ ]

Bangladeshi[ ]

Religion………………………………………………….

Please give details of next of kin & relationship: Name/Address______Tel no: ______

Carers

Your Local Co-Commissioning Group (NHS) and Local authority recognises that informal carers provide invaluable service and are keen to ensure that carers are provided with all available support and information to help them. To this effect, please state if you are an informal carer ordoyYou have a carer, if yes, please provide the

Carer’s Name ______

Are you caring for or helping to care for an ill person, relative, friend or neighbour: (normal care of children who do not have special needs, is not included) YES[ ] NO [ ]Relationship ______

Contact details:………………………………………………………

Do you have a carer? YES [ ] NO [ ] Please give and contact details:…………………………………………………..

AUDIT – C

Questions / Score
0 / 1 / 2 / 3 / 4 / Total
How often do you have a drink containing alcohol? / Never / Monthly or loss / 2-4 times per month / 2-3 times per week / 4+ times per week
How many units of alcohol do you drink / 1-2 / 3-4 / 5-6 / 7-8 / 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? / Never / Less than monthly / Monthly / Weekly / Daily or almost

Total:

Free TBScreening(Eligibility form)

This form will help determine if you are eligible for a FREE TB test. For more information on the TB programme please see

Please complete ALL questions, unless you have circled No to questions 2 or 3.

  1. Please write your country of birth? ......
  2. Have you lived in the UK for less than 5 years? Yes / No (Please circle)
  3. Have you lived in any of the below countries for 6 months or more? Yes / No (Please circle)
  4. Are you between the ages of 16-35? Yes / No (Please circle)

(If you have answered Yes to Questions 2 and 4 or 3 and 4,please continue, if you have answered No to any of the above questions you do not have to complete the rest of this form.)

  1. Are you from/ did you move to UK from one of the following countries, listed below?

Yes / No (Please circle).

Country / Country / Country / Country
Afghanistan / DR Congo / Lesotho / Papua New Guinea
Angola / Djibouti / Liberia / Philippines
Bangladesh / Equatorial Guinea / Madagascar / Republic of Moldova
Benin / Eritrea / Malawi / Rwanda
Bhutan / Ethiopia / Mali / Sao Tome and Principe
Botswana / Gabon / Marshall Islands / Senegal
Burkina Faso / Gambia / Mauritania / Seychelles
Burundi / Ghana / Mauritius / Sierra Leone
Cote d'Ivoire / Greenland / Micronesia
Moldova / Somalia
Cabo Verde / Guinea (Republic of) / Mongolia / South Africa
Cambodia / Guinea-Bissau / Mozambique / South Sudan
Cameroon / Haiti / Myanmar (Burma) / Swaziland
Central African Republic / India / Namibia / Timor-Leste
Chad / Indonesia / Nepal / Togo
Comoros / Kenya / Niger / Tuvalu
Congo / Kiribati / Nigeria / Uganda
DRP Korea / Laos PDR / Pakistan / Tanzania
Zambia
Zimbabwe

5. If you were born in one of the countries above:

Do you have a bad cough? Yes/No ; Do you sweat a lot at night? Yes/No ; Have you lost a lot of weight in the last year? Yes/No

Thank you for completing this form, please hand the forms to reception.

Our practice can send your prescription electronically via EPS (Electronic Prescription Service).

Please nominate a chemist either close to your home or work:

Address………………………………………………………………

…………………………………………………………………………

Postcode:…………………………………

Tel no:…………………………………….

Preferred Communication

If you would like information/ letters in an alternative format, for example large print

or if you need help communicating with us, for example because you use British Sign Language, please let us know either via email, or once registered for online access etc.

Large print[ ]

Sign language[ ]

Braille[ ]

Hearing Loop[ ]

Any other[ ]

Once registered, you will be able to book your own appointments, request repeat prescriptions and view your medical records online. Speak to reception to get your log in details to register through Patient Access.

Consent

Patient records are held on computer as well as paper. Dr L Wong and the Practice Manager, Debbie Nimblette as well as the staff team, are responsible for the confidentiality of these records. On occasion, we share information from yourthe patient records with the health authority, PCTNHS England, hospitals and other NHS/partner organisations in the interest of patient care.

I agree to my medical records being held under the above terms and certify thatthe information I have provided is correct.

I understand that this information will be used exclusively in relation to my healthcare

Signed______Date ______

We appreciate the time you have taken to complete this form. The information you have provided will be valuable in assessing any health needs you may have now or in the future. If you have any queries about this form, please contact the Practice Manager.

Office use only

If patient has answered yes to questions 2 & 4 or 3 & 4 and has circled one of the countries in the table the patient is eligible for TB screening. Please offer the patient a blood test (IGRA) to see if they are at risk of Tuberculosis (TB) .

If the person said Yes to any of the questions in (5) please make an urgent appointment to be screened for active TB

FAO receptionist: If patient is eligible for TB screening, please mark on the top of this form “patient is eligible for LTBI Screening “and hand form to registrations person so patient can be scheduled for a blood test ASAP.FAO: Registration Person, please use the ‘born in read code’ for the country circled above.

Reviewed 30.11.2017sed 17.11.0823.0221.10.0915.10.13