New Patient QuestionnaireToday’s date:

Welcome to the Amersham Vale Practice, we would like to ask you to complete this form. It is of enormous benefit to the doctors and nurses to know something about your medical background when you come to the surgery since we may not receive your medical notes from your previous doctor for sometime

Your allocated GP is:……………………………………………………………………..

GoldsmithStudent/Staff please tick here

Name: …………………………………………………….. / Date of birth: ……………………………………
Address: …………………….…………………………...
………………………………………………...... / Sex: Male Female
Other (please specify)
Telephone number: ………………………………
Next of Kin:…………………………………...... / Mobile number: ………………………………..
Relationship to you: ………………………..
Next of Kin Tel: …......
Main language: ………………………………………. / Interpreter required: / Yes/No
Occupation: …………………………………………….
Ethnic group (optional): / Please circle the one that you think best applies to you – this helps us to monitor that we are reaching all sections of the community.
British / White & Black Caribbean Mixed / Indian / Caribbean / Chinese
Irish / White & Black African Mixed / Pakistani / African / Any other ethnic group
Any other white / White & Asian Mixed / Bangladeshi / Any other Black
Any other mixed / Any other Asian
Smoking
Do you smoke?
 Never smoked
 Ex – smoker – stopped on (please enter date)
 Current smoker – cigarettes per day
Would you like advice on stop smoking services available here? Yes  No 
Alcohol
How many units of alcohol do you drink in a typical week?
1 unit = 1 standard alcoholic drink = half pint beer/lager or 1 pub measure of spirits or 1 small (100ml) glass of wine
Alcohol questionnaire (audit C) / Score 0 / Score 1 / Score 2 / Score 3 / Score 4 / Total score
How often do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 times a month / 2-3 times a week / 4+ times a week
How many standard alcoholic dinks do you have in a typical day when 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
Total score of 5 or more suggests possible harmful drinking.
Would you like advice on services to help you reduce your alcohol intake? Yes  No 
Your Medical History
Please indicate if you have a personal history or family history of any of the following medical conditions.
You
(please include year of diagnosis if you know) / Your close family
(please state if Paternal/Maternal relative and age of diagnosis, if known)
Heart disease
Stroke
High blood pressure
Diabetes
Asthma
Epilepsy
Cancer(please state type)
HIV
Other Past Medical History
At Amersham Vale we encourage all new patients to be tested for HIV and if >40 Diabetes?
I am the person named on this form, and I would like to have the following tests:
HIV Test Yes  No 
Diabetes Test Yes  No (I am over 40 years old)

Please list any regular medication you take…………………………………………………......

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

Please give details of any allergies ………………………………………………………………………………………

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

Women’s Health Screening
When did you last have a smear test (pap smear)? ………………………………………………………….
(the year is sufficient if you can’t remember the actual date)
Do you know the result? Normal  Abnormal  Other 

Are you housebound?YesNo

Are you a carer?YesNo

Would you like to take part in the Patient Participation Group?Yes No 

Please provide your email address for sending agenda and minutes of meetings:

Height in cm …………………Weight in kg ………………… BP…………………………….

Name ………………………………………………………

If filled in on behalf of the patient, relationship to patient ………………………………

Signed ……………………………………… Date ………………………

Email address…………………………………………………………………………………………

I am happy for the Practice to communicate with me via Email…………….Yes/No