As a new patient of the Practice and as it may be some time before your previous medical records are transferred to us, we would be grateful if you would complete this questionnaire about yourself and your family. Please answer all the questions if possible. This will give us important information and help us to offer better care. The information will be kept in your medical record and held in the strictest confidence.
Personal Details
1. Mr Mrs Miss Ms Dr Prof..
2.Surname :
3.First Names :
4.Previous Surname (s):
5.Male Female
6.Date of birth :
7.Nationality :
8. Town and Country of Birth :
9.If you came from abroad, date you came to the uk : / 10.Current address :
Postcode :
11.Home tel : 12. Work tel :
13.Mobile tel :
14.Next of Kin :
Name & Address :
Tel No.
15.Occupation :
Marital StatusSocial Circumstances
. Single Married Widowed
. Separated Divorced / Do you live alone? . Yes . No
Do you care for someone who is ill? Yes No
Language
My main spoken language is :Do you need an interpreter or sign language support? Yes . No
Ethnicity - Please tick one box only
White / Mixed Asian, Asian Scottish or Asian BritishScottish
English
Welsh
Northern Irish
British / Pakistani, Pakitani Scottish or Pakistani British
Indian, Indian Scottish or Indian British
Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Chinese, Chinese Scottish or Chinese British
Other, please specify :
Irish / African, Caribbean or Black
Gypsy / Traveller
Polish
Any other white ethnic group.
Please specify : / African, African Scottish or African British
Caribbean, Caribbean Scottish or Caribbean British
Black, Black Scottish or Black British
Other, please specify:
Mixed or Multiple Ethnic Group / Other Ethnic Group
Any mixed or multiple ethnic group / Arab
Other, please specify :
If you do not wish to give this information, please tick here
Lifestyle
How much do you drink per week?1 pint = 2 units
Glass of wine = 2 units
Spirits = 1 unit
Alcohol units per week =
I never drink alcohol
I stopped drinking on : / How much do you smoke?
Never
I stopped on :
Per day I smoke cigarettes
Per week I smoke cigars
Do you want to stop ?
Yes No N/A
Height =Weight =
Past Medical History
Please list in date order all important illnesses including hospital admissions, special investigations and operations.Date / Details
Are you at present suffering from any illness or receiving any treatment or medicines
Yes No Please give details.
CURRENT ILLNESS / TREATMENT / DRUGS / DOSAGE
Are you allergic to any medicines? Yes No Please give details.
Date / Medication Name / Describe what happened
Family History
Relation / Age / State of Health / If Deceased
Cause of Death / Age at Death
FATHER
MOTHER
SPOUSE
BROTHERS & SISTERS
CHILDREN
Has any relation had?
RelationshipTuberculosis / YES/NO
Diabetes / YES/NO
Cancer / YES/NO / Type :
Kidney Trouble / YES/NO
Angina / Heart Attack / YES/NO
High Blood Pressure / YES/NO
Arthritis (Rheumatism) / YES/NO
Asthma, Hay Fever, Eczema / YES/NO
Epilepsy (Fits) / YES/NO
A Stroke / YES/NO
Mental Health Illness / YES/NO
Females Only
Have you had a cervical smear? Yes No / If YES – date of most recent smear :Are you taking an oral contraceptive? Yes No / Do you have a coil (IUCD) fitted Yes No