Culloden Surgery

New Patient Questionnaire

This questionnaire has been designed to help your new GP practice get to know you and your medical history so please take time to complete it as fully as possible.

PERSONAL DETAILS

Title / Address
First name
Surname
Date of birth
Mobile tel. / Postcode
Work tel. / Home tel.
Occupation / Next of kin
Relationship status / Relationship to next of kin
Next of kin contact details

PLEASE COMPLETE FOR ALL PATIENTS UNDER 16 YEARS

Accompanied today by
Name of school

DISABILITY

Yes/No / If yes, please give details
Do you have a disability?
Do you have a long term condition?
Do you have a carer?
Are you a carer?

CURRENT MEDICATION

Some GP surgeries provide a re-order slip for repeat medication. If you have one of these, please attach it to this form.

Taking medication / Yes/No / Allergic to medication / Yes/No
Details / Details

EXERCISE AND LIFESTYLE

How often do you exercise in an average week? (please tick)
No regular exercise / Once or twice a week / More than twice a week
Do you smoke? (please tick)
I am a regular smoker
How many do you smoke a day? / I have never smoked / I am an ex smoker
When did you give up?
How many did you smoke a day?
How many units of alcohol do you consume in an average week?
(1 unit = ½ pint of beer, 1 glass of wine or 1 measure of spirits)

If you do drink alcohol then please complete the following:

How often do you have 6 (for a woman) or 8 (for a man) standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you failed to do what was expected of you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you not been able to remember what happened when drinking the previous day? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Has a relative/friend/
doctor/health worker ever shown concern about your drinking or advised you to cut down? / No / Yes, but not in the last year / Yes, during the last year

WOMEN

Are you on any form of contraception? If you are, please let us know here
Date of most recent cervical smear / Result of smear
If aged 50-65, date of last mammogram / HPC vaccines

PERSONAL MEDICAL HISTORY

Have you ever suffered from: / Yes/No / Further details
Heart disease?
Stroke or TIA?
Diabetes?
High blood pressure?
Hypothyroidism?
Asthma?
COPD?
Epilepsy?
Mental illness?
HIV?
Other
Please inform us of any allergies here

FAMILY MEDICAL HISTORY (parents, brothers and sisters)

Have any family members ever suffered from: / Yes/No / Further details
Heart disease?
If yes, at what age? / Under 60/Over 60
Stroke or TIA?
High blood pressure?
Diabetes?
Breast cancer?
Ovarian cancer?
Bowel cancer?
Please inform us of any other useful information regarding family history here

Thank you very much for completing this form. If you would like to be seen by our Health Care Assistant for a New Patient Check please contact reception to book a double appointment.

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