Trinity Court & Claverdon Surgery

PATIENT QUESTIONNAIRE

(Patients Over 16 years Only)

NAME:

ADDRESS: POST CODE:

DATE OF BIRTH: OCCUPATION:

EMAIL ADDRESS: HOME TEL.NO:

DAYTIME TEL.NO: MOBILE TEL.NO*:

Please remember to keep your contact details up-to-date.

You can notify us of any changes over the phone, by email or post, or in person at Reception.

WOULD YOU LIKE US TO REGISTER YOU FOR ON-LINE APPOINTMENT BOOKING?

Please complete the appropriate form On-line or from Reception (2 proofs of ID required)

*The surgery uses an appointment reminder service which sends an SMS text message to patients prior to their appointment time. If you would prefer NOT to receive these messages or any other communications to the mobile number you have supplied to us, please tick. £

SMS appointment service provided by Soft Option Technologies ltd, an accredited partner to EMIS, our clinical system supplier.

No patient identifiable or confidential information is transmitted via text message.

Our surgery uploads key health information to the National Database to be used with your consent at appropriate times. If you would like us hide your information from the National Database – Opt-out - please tick below*.

We have more information available at reception – please ask a member of staff.

I would like to OPT-OUT and therefore wish for my ‘Summary Care Record’ to be hidden from the National Database o

*You can change your mind at any time. Please complete a form at Reception.

ETHNIC ORIGIN: (please circle – see list below):

(Asian or Asian British) = Bangladeshi, Indian, Pakistani or other background,

(Black or Black British) = African, Caribbean or other background,

Mixed) = White & Asian, White & Black African, White & Black Caribbean or other background,

(Other) = Chinese or any other,

(White) = British, Irish or other background

First Language: ______

We have been asked to collect this data to help address health inequalities, If you do not wish to provide this info please tick £

Are you a registered Carer? - i.e. Care for someone with a disability Yes / No

If you have declared ‘Yes’ please see reception for our Local Carers Support Information. You are also eligible for the annual seasonal influenza vaccination.

______

All patients have a right to express a preference to received services from a particular doctor. This information will be recorded and we will endeavour to comply with the request although this may not always be possible.

I do / do not have a preference for a doctor: OR Male / Female OR – Dr ______

HEALTH INFORMATION ABOUT YOU

1. FAMILY MEDICAL HISTORY – Have any of your immediate family suffered from any of the follow conditions? If the answer involves grandparents can you state if they are Maternal or Paternal i.e. mother or fathers side of the family)

ü / Family Members ? / Under the age of 60 ? / Over the age of 60 ?
Heart Disease
High Blood Pressure
Diabetes
Cancer (indicate which)
Asthma
Stroke

2. Do you smoke? Yes / No / I’m an Ex-Smoker

Cigarettes ______/ day Pipe ______oz / day Cigars ______/ day

If you are an ex-smoker, which year did you give up? ______

3. Approximate height: ______Approximate weight: ______

Please indicate unit (e.g. Stones, kg, lbs etc…)

4. Do you exercise regularly? Yes / No How often? / times per week

5. Alcohol Consumption

How many units of alcohol do you drink a week? ______(1 unit = 1 small glass of wine / ½ pint of beer/lager)

Questions / Score 0 / Score 1 / Score 2 / Score 3 / Score 4 / Your Score
How often do you have a drink that contains alcohol? / 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 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
Total

6. PERSONAL MEDICAL HISTORY

If you have a medical condition or take any regular medication, please make an appointment to see a GP or Nurse Practitioner before your next prescription is due.

7. PLEASE LIST ANY ALLERGIES YOU HAVE:

NOTE: Assistance dogs:- We are able to give any assistance dogs a tour of the practice areas that will be

accessed by our patients. Please speak to reception should you require this service.

November 2011

January 2012

Reviewed: April 2013 JS