NEW PATIENT QUESTIONNAIRE
To be completed by the person applying to register or their parent/guardian.
Please complete this form in BLOCK CAPITALS
Title: Mr/Mrs/Miss/Ms/Other (please state )
NHS Number (if known):
Surname:
First Name(s):
Date of Birth:
Occupation:
Address:
Postcode:
Email address:
Telephone numbers – Daytime:
Evening:
Can we communicate with you via
Text message?
Mobile:
Yes/No
Email?
Yes/No
(Communications can be more efficient if we are able to use various means).
First spoken Language:
(You can decline to answer)
Are you
housebound?
Yes
No
Are you a Carer?
Do you have a Carer? If yes, please give a name and telephone number
Yes
No
Name, address and contact telephone number of Next of Kin: (Please state whether parent, son,
daughter, etc).
Do you suffer from any of the following? Or does an immediate family member where indicated?
Tick only if affected family
member is a parent, son,
Conditions
You
daughter, brother or sister
Yes
No
Yes
No
Asthma or COPD
Cancer
Diabetes
Thyroid problems
Stroke
Angina/Heart Attack
Blood Pressure
Kidney Problems
Have you received treatment for depression?
Alcohol Consumption – complete if aged 16 and over (Please see appendix 1 for definition of units)
Scoring system
Questions
How often do you have a drink containing
alcohol?
0
1
2
3
4
Never
Monthly
or less
2-4
times a
month
2-3
times a
week
4+
times a
week
Your
score
How many units of alcohol do you drink on a
typical day when you are drinking?
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?
1 -2
3-4
Never
Less
than
monthly
5-6
7-9
Monthly Weekly
10+
Daily or
almost
daily
TOTAL
If you are aged 16 and over, please weigh yourself and check your height and calculate your BMI (see
appendix 1 for instructions).
Height:
Weight:
BMI:
Women’s Health
Are you pregnant?
Have you had a smear?
Yes
Yes
No
No
If yes, when and result?
Have you had a hysterectomy?
Yes
No
If yes, when?
Yes
No
If yes, please specify
Allergies
Do you have an allergic reaction
e.g. rash/collapse, to any
medication and/or eggs?
Please attach a printed list of repeat medication from your previous surgery or list below. State “NONE” if
you are not on any repeated medication. Please use a separate sheet if necessary.
NAME of Medication (State in
DOSE? i.e. 1 a day/2 puffs 4 What complaint is it taken for?
what form e.g. tablets, capsules, times a day
liquid/inhaler)
Please return the completed form to Reception with your medical card (if available). You will also need to
provide proof of ID, address and entitlement to NHS services. This will normally be by production of a
recent utility bill in your name (within the last three months) for the address you live at plus photographic
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ID – passport or driving licence.
If you would like to book a new patient health check with a nurse or health care assistant, please contact us
on 01737 360202.
If patient is under 18 years of age please bring in your child’s immunisation record book.
Patient signature:
..............................................
Date:
..............................................
Print Name:
.............................................
If signing on behalf of the patient please state what your relationship is to the patient.
(e.g. parent, carer, guardian, step-parent, etc.)
Relationship to patient: ..............................................
For office use only
Date of “New Patient Appointment” ………………………………………………..
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New Patient Questionnaire (Appendix 1)
UNITS OF ALCOHOL
1 unit = ½ pint of ordinary beer, lager (Carling/Fosters) or cider (4.0/4.5% of alcohol)
1 small (125ml) glass of wine
1 single pub measure of spirits
1 large pub measure of fortified wine such as port or sherry
1.4 units = ½ pint premium beers and Grolsch/Budweiser/Kronenbourg 1664 (5%)
1.5 units = 1 Large glass of wine (average bottle of wine = 9 units or 6 glasses x 1.5 units)
2.5 units = ½ pint Carlsberg Special Brew/Kestrel Super/Tennents Super (8-10%)
Note: Low alcohol drinks can still contain 1.2% of alcohol and will still increase your blood alcohol levels.
Research shows that no matter what the legal limit it is much safer not to drink and drive at all.
BODY MASS INDEX (BMI) – Only for use by patients aged 16 or over
Clinically, there are few more serious diseases than obesity. Obesity will reduce your life expectancy by six
to seven years. It increases your risk of developing diabetes by more than five times and more than doubles
your risk of high blood pressure. These are only some of the conditions to consider. Obesity can be treated.
Obesity may be indicated from your BMI which can be calculated as follows:
BMI = Weight in kilograms
Height in Metres
e.g.
patient weighing 80kg and 1.76m in height = 80 divided by 1.76 divided by 1.76 = 25.8
A BMI of between 18.5 – 24.9 is regarded as normal, 25.0 – 29.9 as overweight, 30.0 and over as obese
and 35.0 and over as severe obesity (may differ for patients of certain ethnic origins)
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