Maytrees Practice Patient Questionnaire

PATIENT QUESTIONNAIRE

Welcome to Maytrees Practice. To help us with our records, until your notes arrive from the Health Authority, please could you complete this form and we will contact you if we have any queries.

Title: MR/MRS/MS/MISS Date of Birth:

First Name: Surname:

Address:

postcode

Home Telephone Number: Mobile Telephone Number: Email Address:

Carer information

Do you provide care for someone else? YES/NO Do you have anyone who provides care for you? YES/NO Would you like your carer to deal with your health affairs here? YES/NO Does your carer live with you? YES/NO Please provide your carer’s details: Title: Mr/Mrs/Ms/Miss Tel No ……………………………………………………………………………….

First name ………………………………..…………….……………….. Surname ……………………………………….. ……………………

PRESENT ILLNESSES …………………………………. …………………………………………………………………………………………………

PAST MEDICAL CONDITIONS ………………………………………………….. ………………………………………………………………………………..

MEDICATION ………………………………………………………………..……………………….. …………………………………………... ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………..……………………………………….

(It would be helpful if you could bring your repeat prescription slip from your last practice)

FAMILY HISTORY (ie, diabetes, high blood pressure, heart disease, cancer, etc)

………………………………………………………………………………………………..…………………………………

ALLERIGES TO MEDICATION ……………………………..………… OTHER …………………………………………

HEIGHT ……………………………………(cm) WEIGHT ……………………………….………………(kg) Smoking

Are you a smoker? YES/NO Have you ever smoked YES/NO When did you stop smoking? ………………………………………………………….. ………………………………………………………… How many cigarettes do you smoke daily? ………………….…………………………………………………………… If you use rolling tobacco, how many grams a week do you smoke? … ………………………………………… If you are a cigar smoker, how many cigars do you smoke a day? ……………………….……………………… If you are a pipe smoker, how many grams of tobacco do you smoke a week? ……………………………..

Alcohol

…………………………………. units per week (1 unit = ½ pint, 1 measure spirit or 1 glass wine)

Interpreter

Do you need an interpreter? YES/NO Main language? …………………………………………………………………….

Would you like an ‘emergency contact’ added to your records? YES/NO

Title: Mr/Mrs/Ms/Miss Tel No …………………………………………………………………………………….

First name ………………………………..………..…Surname ………………………………….……..……………………

This person’s relationship to you (for example, wife, husband, parent, brother, sister, family member or friend)? …………….…………………………………….…………….…

Do we have your permission to discuss your health affairs with this person? YES/NO

Would you like a ‘next of kin’ contact added to your records? YES/NO

Title: Mr/Mrs/Ms/Miss Tel No …………………………………………………………………………………….

First name ………………………………..…………Surname ……………………….………………..……………………

This person’s relationship to you (for example, wife, husband, parent, brother, sister, family member or friend)? ………….…………………………………….…………….…

Do we have your permission to discuss your health affairs with this person? YES/NO

If this is a registration for a child, please enter parent/guardian details -

Title: Mr/Mrs/Ms/Miss First name ………………………………Surname ……………………………………………

Title: Mr/Mrs/Ms/Miss First name …………………………… Surname ………………………………………….. We aim to provide good health services for all people. In order to do this we need to know more about the population we are serving and are therefore asking you to answer 3 questions on this form.

This will help us to provide the right type of healthcare services for all our patients. We need to know about language, interpretation needs, and about our population’s religious and cultural requirements.

The personal information you give us on this form will have the same level of confidentiality as your medical record. This means it will not be shared with any other organisation, including other government departments, such as the Home Office or the Inland Revenue. If you have any concerns about the use of the information, please talk to a member of staff at your practice.

Thank you for helping us provide a better service to you. ______

1. What do you consider to be your ethnic origin?

Asian or Asian British White Bangladeshi British Indian Irish Pakistani Gypsy Asian other (please state Traveller ………………………………… White other (please state) …………………………………………………………………… Black or Black British African Other Ethnic Group Caribbean Chinese Black other (please state) Any other (please state) …………………………………… ……………………………………………………… Mixed Background White and Asian Other mixed background (please state) White and Black African …………………………………………………………………….. White and Black Caribbean

2. How would you describe your religion?

Christianity (all denominations) Hinduism Islam Buddhism Judaism None Sikhism Other (please state) ……………………………..

3. In the clinic, which language do you usually speak and read?

Speaking Reading Speaking Reading English Polish Albanian Punjabi Arabic Russian Bengali Somali Cantonese Spanish Farsi Turkish French Urdu Gujarati Hindi Other (please state) Mandarin …………………………………

Thank you for helping us ______

Signed ………………………………………………………………………………………………… Date ………………………………………………………………………………