New Patient Questionnaire

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

What is your height? *

What is your weight? *

What is your first language? *

Do you need an interpreter? *

Yes No

Ethnic Group *

Please list any medicines being taken and the amount:

Are you registered disabled? *

Yes No

If yes, please give details

Are you allergic to any medicines? *

Yes No

If so, which?

If so, what and when?

Have you ever suffered from? (tick as appropriate)

Anxiety

OCD

Depression

Bipolar Disorder

If yes to any of these, please state the year(s) when were you first diagnosed?

Do you have any other mental health issues? *

Yes No

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Do you hold a Living Will? *

Yes No

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Do you use a Vape or an Electronic device? *

Yes No

Would you like advice on giving up smoking? *

Yes No

Are you teetotal? *

Yes No

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Please give name, address, telephone number and relationship of next of kin *

Which Pharmacy would you like your prescriptions to be sent to? *

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

Yes No

Signature *

Date *

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