`MEDICAL QUESTIONNAIRE – 19 Beaumont Street Medical Practice

Surname / Date of Birth / day month year
/ /
Forename / Sex / Female  / Male 

For students

Name of College: / Home Tel No:
Oxford Address:
(NB for students this will be your college address)
Postcode: / Mobile No:
Email Address: / We may use your email address to contact you on matters relating to your health care
Personal Status: / Single / Married / Separated / Divorced / Widowed / Cohabiting
Person(s) to be contacted in event of serious accident or illness / Tel No:
Relationship
Do you look after someone? / YES / NO / Does someone look after you? / YES / NO
Are you part of a family who will all be registering with us? / YES / NO / If so please name the other family members here:-
Previous Doctor / For students:
Course / Subject
Address / For students:
Graduation Date
Country of Origin & Ethnic group
Please tell us about your medical history. This section is important for all new patients but particularly those who will be coming from outside the UK for the first time as your records will not automatically follow you. There is no need to mention minor complaints but all significant conditions, operations and injuries should be included, even if they are now fully resolved. Please include significant emotional or psychological issues if you needed help for them. Below are three examples of the most helpful format in which torecord this information. If you need more space please continue onto a new page. If there is no significant medical history then please say so.
Date or year of onset / Name of condition or medical event / Details of treatment and progress / Is the condition current? If not, when did recovery occur?
Examples:-
1990
1987
1994 / Asthma
Fractured right femur due to car accident.
Moderate depression / Salbutamol and Beclomethasone inhalers. Well controlled, no hospital admissions required.
Internal fixation at such & such hospital by Mr/Dr so & so.
Due to family problems. Counselling and short term medication. / Ongoing maintenance treatment.
Recovered 1988 but right leg shortetened.
Fully resolved by 1995
Below is a list of activities which may affect your health:-
Do you smoke? / YES / NO / Height:
If YES, how many each day? / Weight:
How long have you smoked? / What is your diet? / Normal  / Vegetarian  / Other 
If NO, have you ever smoked? / YES / NO / Are you worried about your weight or diet? / YES / NO
Date stopped / If so, why?
Do you take regular exercise to keep fit? / YES / NO
If yes, how many times per week?
Are you taking any medicines / pills / inhalers or using any ointments? (if YES, please give details below)
Name of Medicine / Dose and Frequency of Use / Date Started

Have you used an inhaler (of any type) in the last 12 months Yes / No

Have you ever had an adverse reaction or allergy to any medications or other substances? If yes please give details below:-
Name of medicine or substance / Nature and date of reaction
Below left is the immunisation schedule given to most children in the UK who would now be 18 years old. Please indicate which immunisations you have had.
Age Vaccine Usually Given / Disease / Have you been given this vaccine? / If YES, date given / Other Vaccines / Date Given
3 times in First Year of Life / Diphtheria / Tetanus / Pertussis (DTP or ‘Triple’) / YES / NO / Unknown / MenC
Hib
13 months / Mumps, Measles, Rubella (MMR) / 1st Dose / YES / NO / Unknown / Pneumococcal
Pre-School / 2nd Dose / YES / NO / Unknown / Hep A
3 – 5 years / Diphtheria, Tetanus, Polio, ‘Dip / Tet’ / YES / NO / Unknown / Hep B
10 – 14 years / Heaf Test & BCG (for TB) / YES / NO / Unknown / Others
13 – 18 years / Diphtheria, Tetanus, Polio / YES / NO / Unknown / Others

ALCOHOL SCREENING – Alcohol Users Disorders Identification Test (AUDIT) C - It is a government priority to address the issue of illness associated with increasing alcohol consumption for patients aged 16 yrs and over. Please tick as applicable

SCORING SYSTEM / Score
Questions / 0 / 1 / 2 / 3 / 4
How often do you have an alcoholic drink / Never / Monthly or 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 / 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/almost daily
Total
1 unit = single measure spirits
2 units = a glass of wine or pint of regular beer/lager/cider / 1.5 units = a can of lager of alcopop
9 units = bottle of wine

FOR WOMEN

Do you use any form of contraception? / YES / NO / Have you ever had a cervical smear?
(1st smear now recommended age 25) / YES / NO
If YES, method used / Date of Last Smear
Result (i.e. normal, abnormal etc)
How long have you used this method? / Was it taken by your GP? / YES / NO

IF COMPLETING THIS ELECTRONICALLY PLEASE MAIL BACK TO