New Patient Questionnaire - Under 16's | Over 16's

Fields marked with a * are compulsory.

* Name: * Date Of Birth: * Address: * Marital Status: Married Single Divorced Widowed Separated Telephone No: * E-Mail Address: Occupation * Repeat E-Mail: Are you a Carer? Main carer for someone else? Who for? Which ethnic group do you belong to? - You are not obliged to complete this section. Please tick as appropriate White 9S1 Chinese 9S9 Indian 9S6 Bangladeshi 9S8 Pakistani 9S7   Black-African 9S3   Black Caribbean 9S2   Other - please state I do not wish to give this information   IF YOU ARE A WOMAN   Have you had any Miscarriages? Yes No N/a Stillbirths? Yes No N/a       Livebirths?   Are you using any form of contraception at present? Yes No N/a     If Yes what method? N/a Pill Coil Cap Condom Sterilised Depoprovera Injection Implants     When was your last check up?     Have you had a cervical smear? Yes No N/a   If YES, when?   Have you had a mammogram? (age 50 onwards) Yes No N/a     Have you had a Rubella immunisation? Yes No N/a     Medical History   Previous Serious Illness Operations Dates             Present regular medication (please list name, strength and how often taken) Name Strength How Often Taken 1: 1: 1:   2:   2:   2:   3:   3:   3:   4:   4:   4:   5:   5:   5:   6:   6:   6:   7:   7:   7: Drug Allergies 1: 3:   2:   4: Family History Is there anyone in your family who has had: (is so at what age) Heart disease < 60yrs old Please give details Stroke   Please give details   Cancer   Please give details   Diabetes   Please give details   Asthma   Please give details   Smoking Habits Smoker? Number Of cigarettes/ Cigars per day:   Non-Smoker?         Ex-Smoker?   Number Of cigarettes/ Cigars per day: Date stopped Alcohol Intake Please estimate your alcohol intake per week (1 unit = half a pint of beer or 1 glass of wine or 1 measure of spirit Number of units per week How many times per week do you exercise for 20 minutes or more? Current Height Ft In Current Weight St Pd I understand that email cannot be guaranteed as totally secure and confidential. The Practice cannot take responsibility for any problems arising through the use of this on-line request. Tick the box below to accept these terms and conditions and then submit your request. I accept the terms and conditions above