New P Questionnaire.Indd

NEW ADULT PATIENT County Post Code (16+YEARS) Were you registered with your previous GP at this address? Y / N PLEASE COMPLETE THIS FORM CLEARLY IN CAPITAL LETTERS USING BLACK INK if No, what address does your previous GP PERSONAL DETAILS have for you? ...... YOUR NHS NUMBER: ...... TITLE: Mr / Mrs / Miss / Ms / ...... Other ...... SEX: Male / Female ...... SURNAME PREVIOUS SURNAME PREVIOUS FORENAME(S) GP GP’s DATE OF BIRTH Name TOWN & COUNTRY OF BIRTH Practice ETHNIC ORIGIN Name LANGUAGE……….. INTERPRETER Y/N Practice RELIGION Address Practice Telephone CONTACT DETAILS

NO & STREET TOWN COUNTY POST CODE HOME PHONE WORK PHONE MOBILE PHONE HOME E- MAIL EMERGENCY CONTACT NAME EMERGENCY CONTACT’S PHONE DO YOU LIVE IN A CARE / NURSING HOME? Y / N ARE YOU A CARER?

PREVIOUS DETAILS

PREVIOUS ADDRESS No & street Town spirit) The Ridgeway Surgery Have you lived abroad in the last 5 years? Y / Welcome to our surgery N If so, which countries? As part of our commitment towards improving health we expect: If you travel abroad regularly, are you up-to-  all qualifying women (25 to 65 years) date with your travel vaccinations? Y to be up-to-date with cervical screening. / N  all patients with chronic medical conditions (e.g. heart disease, diabetes, asthma, epilepsy, chronic lung disease, etc) PAST & PRESENT MEDICAL HISTORY should make an appointment with our nurse as soon as possible. Include hospital admissions, operations,  If you are on repeat medication please accidents, and chronic or serious illnesses attach a copy of your medication list and Condition Month / Year bring the list (or all your medicines) along on your 1. first appointment. 2. YOUR GENERAL HEALTH 3. Height: Weight: 4. Exercise level: none / light /moderate / 5. vigorous Special diet? Y / N If yes ...... Smoker? No 6. Never / Ex-smoker stopped ...... Smoker? 7. Yes Smoke...... /day since ...... 8. 9. Alcohol intake: ...... Units/wk (1 unit=1/2 beer, small glass wine, 1 single 10. ALLERGIES Do you suﬀer from any of the following? List any reactions to drugs, plasters, foods, etc What triggers it? Description of reaction Raised blood pressure Y / N Previous heart attack or angina Y / N Stroke or TIA Y / N Diabetes Y / N Chronic kidney condition Y / N YOUR MEDICATION Asthma or chronic lung condition Y / N List your regular medicines including any over the Cancer Y / N counter or complimentary medicines Mental health problems Y / N 1. Immune suppression conditions or drugs Y / N 2. 3. FOR FEMALES ONLY 4. 5. Have you had a cervical smear Y / N 6. If Yes, when?...... where? previous GP, other...... 7. Smear result normal/abnormal/not sure 8.

9. Have you contraception needs? Y / N 10. If Yes, current method......

Have you had a hysterectomy? Y / N If Yes, reason?...... YOUR PRESENT HEALTH STATUS Date of operation: ...... Prior to joining us have you been attending any: nurse clinic at your previous GP’s? Y / N

If so, what for...... THANK YOU FOR COMPLETING THIS FORM

If so, what for...... Treatment Disclaimer hospital clinics? Y / N You have been registered at this Practice and are eligible for free Primary Care treatment If so, what for...... at this practice. This does not, however, necessarily entitle you to free NHS Secondary If so, what for...... treatment or treatment elsewhere.

If so, what for...... any other health professional ? Y / N

 If so, what for...... Data transferred to Vision  For scanning into records