NEW PATIENT QUESTIONNAIRE
SURNAME:……………………………………DATE OF BIRTH…………………………
FORENAME:………………………………………MARITAL STATUS M / S / OTHER
ADDRESS:……………………………………………………………………………………
…………………………………………………………………………………………………...
TELEPHONE NO: ………………………………..
PREVIOUS ADDRESS:……………………………………………………………………
……………………………………………………………………….………………………….
PREVIOUS DOCTOR’S NAME AND ADDRESS: DR:………………….………….
…………………………………………………………………………………………………
………………………………………………………….……………………………………...
Please record any SERIOUS illnesses or operations and the year in which they occurred:
………………………………………………………………………………………………….
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Are you allergic or sensitive to anything? (e.g. Penicillin) YES NO
If YES please give details……………………………………………………………………...
Are you taking any tablets regularly? YES NO
If YES: a) When you come to see the doctor for the first consultation please bring all your medication with you.
b) Please record the names of the drugs.
………………………………………………………………………………………………….
Do you voluntarily look after someone? Yes …………… No ……………….
Does someone voluntarily look after you? Yes …………… No ……………….
SMOKING STATUS:
(please tick) Never smoked Current Smoker Ex Smoker
PLEASE GIVE REASON FOR LEAVING LAST PRACTICE?
………………………………………………………………………………………………….
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If you are a woman:
Have you had a cervical smear? YES…………NO…………
If YES when was the last one?……………………………………….
Are you taking the contraceptive pill, or do you have a coil fitted? YES………NO……….
Have you been pregnant? YES………..NO…………
If YES, 1) How many times?…………………..
2) Have you had any miscarriages? YES…………NO…………
Have you had a German Measles (Rubella) vaccination? YES…………NO…………
IF YOU HAVE CHILDREN YOU WISH TO REGISTER WITH US PLEASE GIVE THEIR FULL NAMES AND DATES OF BIRTH. ALSO NOTE IF THEY HAVE HAD ANY SERIOUS CHILDHOOD ILLNESS.
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What is your ethnic group?
Choose ONE section from A to E, then tick the appropriate box to indicate your cultural background.
Do you need an interpreter or sign language support
If you need an interpreter what language do you speak?
Please state …………………………………………….
What is your ethnic group?
Choose ONE section from A to E then tick ONE box which best describes your ethnic group or background
A White
Scottish
English
Welsh
Northern Irish
British
Irish
Gypsy/Traveller
Polish
Any other White background, please write in …………………….
B Mixed or multiple ethnic groups
Any Mixed background, please write in …………………………..
C Asian, Asian Scottish, or Asian British
Pakistani, Pakistani Scottish or Pakistani British
Indian, Indian Scottish or Indian British
Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Chinese, Chinese Scottish or Chinese British
Other, please write in ………………………………………………….
D African, Caribbean or Black
African, African Scottish or African British
Caribbean, Caribbean Scottish or Caribbean British
Black, Black Scottish or Black British
Other, please write in …………………………………………………….
E Other ethnic group
Arab
Other,please write in ………………………………………………………
If you do not wish to give this information, please tick here
THANK YOU FOR YOUR HELP
S:\REGISTRATION\new patient questionnaire.doc