Dr Mansbridge and Partners

BARNFIELD AND PARTNERS LORDSHILL HEALTH CENTRE

NEW PATIENT QUESTIONNAIRE

In order for us to provide you with the best medical care, please complete this questionnaire and hand to Reception. All the information provided by you will be handled confidentially.

NAME MR/MRS/MISS/MS/OTHER ETHNIC FIRSTLANGUAGE Refused ORIGIN

DATE OF BIRTH OCCUPATION

HOME PHONE NUMBER ………………………… NEXT OF KIN or CONTACTS IN AN EMERGENCY

MOB MOBILE …………………………………………….. Name

WORK ………………………………………………. Relationship We offer a text messaging service. Please indicate if you consent for us to text you for appointment reminders and Health Promotion information. Phone number(s) YES NO

ARE YOU A CARER? DO YOU HAVE A CARER? Please complete the carers form

DO YOU OR A CLOSE FAMILY MEMBER (Mother, Father, Brothers or Sisters) SUFFER FROM ANY OF THE FOLLOWING?

ILLNESS SELF FAMILY ILLNESS SELF FAMILY YES/NO YES/NO YES/NO YES/NO Thyroid Heart Disease problems High Blood Cancer Pressure Mental Health Stroke problems

Diabetes Epilepsy Asthma/Chronic Lung Chronic Kidney Disease Disease DRUG ALLERGIES If so tell us what the drug was and what allergy it caused. Yes or No

NON-DRUG ALLERGIES For example - nuts, tomatoes, animal fur. Yes or No

REGISTERED GP …………………………………………………………………………………

APPOINTMENT MADE WITH GP or NURSE - date and time ………………………………

Thank you for taking the time to complete this form; it will help us to help you.

MS Debra Charman Practice Manager

Office use Repeat Meds…. Photo ID …. Add ID ….. Ethnicity …. BP. Smoking Status ... Pat Sig.. . Next of Kin … Carer ….. Checked Page 2

ABOUT YOURSELF

Name ………………………………………………….. Date of Birth ……………………………

BP Reading ……………… Pulse ………….. Date taken ………………...

Please use BP machine in Reception

DO YOU SMOKE? Yes / No If yes how many Cigarettes per day …………………

(office use only) Are you an ex-smoker? Yes / No Quitters form given When did you give up ………………………………

WEIGHT HEIGHT

EXERCISE A – Aerobic exercise 3+ times per week B – Aerobic exercise 1-2 times per week How much exercise do you do per C – Regular Swimming or Cycling week? D – Daily Walking E – Exercise physically impossible

DIET GOOD AVERAGE LOW FAT HIGH FAT How would you describe your diet? POOR VEGETARIAN

ARE YOU CURRENTLY PREGNANT ? Yes No

If Yes, when is your baby due? …………………………………

Have you had your booking appointment? Yes No

ILLNESS

Have you had any illness or operations? If yes please give date and diagnosis/type of operation.

MEDICATION

Please list any regular medication that you are taking or give us a copy of your repeat order slip from your previous surgery