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New Patient Questionnaire
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New Patient Questionnaire
YOUR CONTACT DETAILS
Title
Mr
Miss
Mrs
Ms
Name
Required
Date of Birth
Required
Date
Previous Surname
Address
Required
Address 1
Address 2
City
Country
Select a country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St Barthélemy
St Helena
St Kitts & Nevis
St Lucia
St Martin
St Pierre & Miquelon
St Vincent & the Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
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Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
County
Postal Code
Home Number
Mobile Number
Required
Email Address
Required
_____________________________________________________________
INFORMATION ABOUT YOU
What is you height?
Required
What is your weight?
Required
What is your first language?
Required
Do you need an interpreter?
Required
Yes
No
Ethnic Group
Required
White British
White Irish
White Other
Black British
Black Caribbean
Black African
Black Other
Asian Indian
Asian Pakistani
Asian Chinese
Asian Other
White & Black British
White & Black Caribbean
White & Black African
White & Asian
Other
_____________________________________________________________
PREVIOUS GP
Name and Address of Previous GP
Required
_____________________________________________________________
PROOF OF IDENTITY AND ADDRESS PROVIDED
Identity Document Type
Required
Birth Certificate
Driving Licence
Passport
Utility Bill
Allowance Book
Solicitors Letter
Offer of Tenancy
Other
Other
Please list any serious illness / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place
Have you ever suffered from? (tick as appropriate)
Eplilepsy
Blindness/Glaucoma
High Blood Pressure
Diabetes
Heart Attack/Stroke
Depression
Cancer
Asthma
Eczema/Hay Fever
COPD
If yes, please state the year(s) when you were first diagnosed?
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?
Required
Yes
No
If so, which?
Have you ever refused treatment/screening of any kind?
Required
Yes
No
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)
_____________________________________________________________
CARERS
Do you have a carer?
Required
Yes
No
If yes please give details
Are you a carer?
Required
Yes
No
If yes please give details
_____________________________________________________________
WOMEN
Have you ever had a cervical smear?
Required
Yes
No
if 'yes', please state when, where and the result
_____________________________________________________________
WILL
Do you hold a Living Will?
Required
Yes
No
_____________________________________________________________
SMOKING
Do you smoke?
Required
Yes
No
If 'No', have you ever smoked?
Required
Yes
No
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?
Required
Would you like advice on giving up smoking?
Yes
No
_____________________________________________________________
ALCOHOL
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
Required
Please select an answer
Never
Less than monthly
Monthly
Weekly
Daily
How often during the last year have you failed to do what was normally expected of you because of drinking?
Required
Please select an answer
Never
Less than monthly
Monthly
Weekly
Daily
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?
Required
Please select an answer
No
Yes, on one occasion
Yes, on more than one occasion
_____________________________________________________________
FAMILY HISTORY
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.
Required
_____________________________________________________________
NEXT OF KIN
Please give name, address, telephone number and relationship of next of kin
Required
_____________________________________________________________
FOR PATIENTS AGED 65 AND OVER OR THOSE WITH A CHRONIC DISEASE (E.G. ASTHMA OR DIABETES)
Have you had a flu vaccination? Enter date or 'never'
Required
Have you had a pneumococcal vaccination? Enter date or 'never'
Required
_____________________________________________________________
CONTACTING YOU
Do you agree that you may be contacted from time to time, via email and/or SMS, with p.ractice news, advice about my health and/or appointment reminders
Required
Yes
No
SIGNITURE
Signature
Required
Date
Required
Date
Privacy policy
Required
I agree to the
privacy policy
Submit
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