New Patient Questionnaire Adults (aged 16 and over) Contact DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last GenderPlease selectFemaleMaleDate of Birth Day Month Year Address Street Address Address Line 2 City Postcode Mobile numberHome numberWork numberEmail Enter Email Confirm Email Preferred contact method Text Message Email Telephone Letter Do we have your permission to contact you by Text Message Email Voicemail Marital status Single Divorced Married/Civil Partnership Widowed Next of Kin Name First Last Next of Kin Contact NumberRelationship to you Do you have any family registered with us? Yes No Please specify the family that are registered with usOther DetailsPrevious GP Previous GP Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Country of Birth Armed Forces Military Veteran Family member Date of enlistment: Day Month Year Date of discharge: Day Month Year EthnicityPlease selectWhite (UK)White (Irish)White (Other)Black BritishBlack )Other)Mixed BritishBangladeshiChineseIndianPakistaniOtherOccupation Health Record SharingWhen you need medical help it is essential that NHS services can securely access your help record. Do you consent to your GP health record being made available to other NHS care services that care for you? Yes (recommended) No, except in an emergency Never Do you consent to your GP Practice viewing your help record from other services that care for you? Yes (recommended) Never Communication NeedMain spoken language Do you need an interpretor?Please selectYesNoDo you have any communication needs? Yes No Untitled British Sign Language Large Print Hearing aid Guide dog Makaton Sign Language Braille Lip reading Carer DetailsAre you a carer? Yes – Informal / Unpaid Carer Yes – Occupational / Paid carer No Do you have a carer? Yes No Only add carer’s details if they give their consent to have these details stored on your medical record. Name First Optional Last Optional Contact number OptionalRelationship to you Optional AlcoholPlease answer the following questions which are validated as screening tools for alcohol use:How often do you have a drink containing Alcohol?Please selectNever (0)Monthly or Less (1)2-4 times per month (2)2-3 times per week (3)4+ times per week (4)UnitsPlease select1-2 (0)3-4 (1)5-6 (2)7-9 (3)10+ (4)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?Please selectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4) A score of less than 5 indicates lower risk drinking Scores of 5 or more require the following 7 questions to be completed:Total Score: 4 or less 5 or more SmokingDo you smoke? Never smoked Ex smoker Yes Do you use an e-Cigarette? No Ex-User Yes How many cigarettes did/do you smoke a day? Less than one 20-39 1-9 40+ Would you like help to quit smoking? Yes No For further information visit: www.nhs.uk/smokefree.Height and WeightHeight cm/ftWeight kg/stHealth InformationDo you suffer from any of the following illnesses? Heart Disease Raised blood pressure Stroke or TIA Asthma COPD Type 1 Diabetes Type 2 Diabetes Thyroid disorders Epilepsy Mental health problems Kidney disease None of the above Do you have any other serious illnesses? Yes No Please specifyDo you have any allergies? Yes No Please specifyAre you taking any regular medication? Yes No Please specifyNominated Pharmacy OptionalPlease state the name and branch of the Pharmacy that you would like to process your prescriptions (via NHS Electronic Prescription service): SignaturesConsent I confirm that the information I have provided is true to the best of my knowledgeSignature
