South Hetton Health Centre, Front Street, South Hetton, Durham, DH6 2TH
T: 0191 517 1055 F: 0191 526 0001 E: [email protected]
New Patient Questionnaire
Surname:
Forename (s):
Title: Mr / Mrs /
Ms / Miss
Date of Birth:
Maiden name(s):
Address:
Post Code:
Telephone number:
Mobile number:
Current occupation:
Marital status:
Single / Married
/ Widow/Widower /
Divorced/Separated
/ Other
Ethnic group
To which of these groups do you consider you belong?: (tick one box only)
White:
British
Irish
Any other White background
Black or Black British:
Caribbean
African
Any other Black background
Asian or British Asian:
Indian
Pakistani
Bangladeshi
Any other Asian background
Mixed:
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background
Ethnic Groups:
Chinese
Any other Ethnic group
Prefer not to disclose
Your religion:
Your main spoken language:
Do you speak English?:
Yes / No
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South Hetton Health Centre, Front Street, South Hetton, Durham, DH6 2TH
T: 0191 517 1055 F: 0191 526 0001 E: [email protected]
Please answer the following questions:
1. Are you a carer?
Yes
No
If so, do you consent to us recording this on our system?
Yes
No
By providing this information it will enable us to flexibly meet your needs.
2. Are you a Military Veteran?
Yes / No
Armed forces, regular or reserve, Merchant Navy seafarer and/or fisherman who served in a
vessel which facilitated military operations by armed forces.
If YES can we record this on your medical record?
Yes / No
3. Smoking
Do you smoke?
Never smoked
If yes how many per day?
If ex smoker how long have you been stopped?
Ex smoker
Yes
4. Alcohol
How often do you have a
drink that contains
alcohol?
On a day when you are
drinking alcohol, how
many standard drinks do
you have?
How often do you have 6
or more standard drinks
on 1 occasion?
How many alcoholic
units/drinks per week?
Never
Monthly or
less
2-4 times
per month
2-3 times
per week
4+ times per
week
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
0
1-10
10-20
20-30
30+
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South Hetton Health Centre, Front Street, South Hetton, Durham, DH6 2TH
T: 0191 517 1055 F: 0191 526 0001 E: [email protected]
5. Your Height?
Your Weight?
6. Do you have any current medical problems?
Yes
No
If yes please give details:
7. Have you had any other illnesses, accidents or operations in the past?
Yes
No
If yes please give details:
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South Hetton Health Centre, Front Street, South Hetton, Durham, DH6 2TH
T: 0191 517 1055 F: 0191 526 0001 E: [email protected]
8. Are you under the care of a hospital consultant at the moment?
Yes
No
Name of consultant:
Hospital:
Diagnosis:
9. Do you take any regular medication?
Yes
If yes please give details:
10. Do you have any allergies to medicines or tablets?
Yes
No
No
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South Hetton Health Centre, Front Street, South Hetton, Durham, DH6 2TH
T: 0191 517 1055 F: 0191 526 0001 E: [email protected]
If yes please give details:
11. From which pharmacy would you like to
collect your prescriptions?
12. Are there any parts of your medical records
marked – Private?
Yes
No
13. Female Patients Only
Contraception method (if applicable):
Date of last cervical smear:
Result:
Date of last breast screening:
Result:
14. Family History
Do you have any family members who have suffered or are suffering from:
Heart conditions
Yes / N o
Stroke
Yes / N o
Diabetes
Yes / No
A hereditary condition
Yes / No
Other disease
Yes / No
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South Hetton Health Centre, Front Street, South Hetton, Durham, DH6 2TH
T: 0191 517 1055 F: 0191 526 0001 E: [email protected]
15. Summary Care Record
Your summary care record will be transferred from your previous GP, or we will create a new
one for you
See enclosed leaflet
If you do not want a Summary Care Record please complete the enclosed Opt Out form
and return it to the surgery with this patient questionnaire.
16. Online Services
We can offer you access to online services such as booking appointments and ordering repeat
prescriptions. If you would like to be registered for this service your username, password and
instructions will be sent out to your home address in the mail
Yes
No
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