The Limes Medical Centre
New Patient Questionnaire
Please take time to complete the questionnaire as fully as possible
Personal Details
Title:______Family name:______
Given name:______Middle name:______
Known as:______Previous family name:______
Date of birth:____/____/____NHS Number______Gender M/F
Marital Status______Interpreter required: Y/N
Main spoken language English Y/NEnglish as a second languageY/N
Main spoken language Italian Polish Romanian Hindu Other______
Ethnicity: (Please state)
British/Mixed______Other White______
Other Mixed______Other Asian______
Other Black ______Other______
Home Address
House Name/Flat Number______Number & Street______
Locality______Town/City______
County______Postcode______
Contact Details
Home Telephone No:______Work Telephone No:______
Mobile No:______Email Address:______
Occupation______
Medical History:
Usual GP:______Hospital Number______
Records at:______
Personal Medical History:
Please list any serious illnesses, hospital admissions or operations you have had:
Date / ProblemFamily Medical History:
Have any of your close relatives suffered or died
from any of the following:
Relation / Age of onsetHeart attack / Y/N
Angina / Y/N
Stroke / Y/N
High blood pressure / Y/N
Diabetes / Y/N
Cancer / Y/N
Which type______
Drugs and Medicines:
Please specify all drugs, medicines, tablets or pills that you take regularly:
Name:Dose:
______
______
______
Allergies:
Drug Allergy…………………………………… Penicillin or Other Antibiotic…………………………..
Food Allergy…………………………………… Any other allergy……………………………………….
Your Health:
Are you a:
SmokerY/NIf Yes how many years______
Ex-SmokerY/N
Non/SmokerY/NWould you like to stop smoking Y/N
Cigarettes Y/NHow many per day______
CigarsY/N
Roll your ownY/NWould you like to stop smoking Y/N
PipeY/N
Do you drink alcoholY/N
How many units per week______1 unit = ½pint of beeror 1 measure of spirits or 1 glass of wine
Your height ______Your weight______
What form of exercise do you take?
NoneY/NWorkY/N
GymY/NTimes weekly______
SwimmingY/NTimes weekly______
WalkingY/NTimes weekly______
RunningY/NTimes weekly______
Women:
Please give the date and result of your last smear______
(If aged 25yrs – 65yrs)
Please give the date and result of your last mammogram______
Immunisations
Have you been immunised against:Meningitis CY/N/Unsure If yes, date______
TetanusY/N/UnsureIf yes, date______
Hepatitis BY/N/UnsureIf yes, date______
Any other injections______Date______
______Date______
Next of Kin/Emergency contact:
Name______(Relationship)______
Address______
Phone no. Home______Work ______Mobile______
Do you look after someone?Y/N
Does someone look after you?Y/N
Are you a registered carer?Y/N
Are you a full time carer for anybody, If so who?Y/N if yes please give details:
______
Patient Signature______Date______
(Parent or Guardian for minors)
All new patients are asked to make an appointment for a new patient check with our nurses.
PLEASE BRING A URINE SAMPLE WHEN YOU ATTEND
May we refer you to our practice leaflet. Please read it carefully as it contains lots of useful information regarding the practice.
AUDIT – C (For over 16 yrs only)
Patient Name:
EMIS Number:
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly
or less / 2 - 4 times per month / 2 - 3 times per week / 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? / 1 -2 / 3 - 4 / 5 - 6 / 7 - 9 / 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Scoring:
A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.
Score from AUDIT- C (other side)
Remaining AUDIT questions
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often during the last year have you found that you were not able to stop drinking once you had started? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Have you or somebody else been injured as a result of your drinking? / No / Yes, but not in the last year / Yes, during the last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? / No / Yes, but not in the last year / Yes, during the last year
Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence