The Hackwood Partnership New Patient Questionnaire

The Hackwood Partnership – New Patient Questionnaire

Welcome to our surgery. We would very much appreciate you taking the time to complete this form as fully as possible.

First Name……………………………………Surname……….……..……………………………………… Date of Birth:……………… Email address:……………………………………………………………… Tel: Mobile:………….………………..Work:….…..…………………. Home:………………………….

Are you happy for us to contact you for appointments and information via text message? YES/NO

How did you hear about us?...... Ethnic Origin…………………………………….First language…………………………………….

Medical History – Please list, with dates, any significant health problems, including hospital admissions, operations or ongoing conditions. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………

In particular, do you have or have you ever had any of the following conditions? Please tick:  Diabetes  Heart disease (a history of angina or heart attack)  Stroke or mini-stroke (TIA)  Raised blood pressure  Asthma or COPD (Chronic Obstructive Pulmonary Disease)

Family History – Please list any significant illnesses that run in your family, including those listed above: ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………

Regular prescription medicines – if you have been taking repeat medications from your previous doctor, please attach a print-out of your repeat prescription to this form AND complete the table below. We will contact you if we need you to make an appointment for review – this may be with a nurse or a doctor.

Drug Name Strength Frequency Reason for taking

PTO Allergies (especially medication)…………………………………………………………

Are you a carer? Yes/No If yes, please give details of the person you care for and their condition: …………………………………………………………………………………………………………

Do you smoke? Please circle: Yes – how many per day?...... Ex-smoker – date stopped……….. Never If yes, would you like us to call you to discuss what help is available? Yes/No Further information can be found at www.quit4life.nhs.uk

Do you drink alcohol? Yes/No If yes, please complete the following: How many units per week?...... 1 unit = ½ pint of beer, 1 small glass of wine or 1 single spirit

1. MEN - How often do you have 8 or more drinks on one occasion? WOMEN – How often do you have 6 or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily

2. How often in the last year have you been unable to remember what happened the night before because you have been drinking? Never Less than monthly Monthly Weekly Daily or almost daily

3. How often in the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily

4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggest you cut down? No Yes, on one occasion Yes, on more than one occasion

For women only: Date of last smear test…………………….Was your last smear normal? Yes/No Have you been immunised against rubella? Yes/No Have you had a hysterectomy? Yes/No

Next, please use the machines in reception to check your height, weight and blood pressure and hand the print-outs to reception.

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For office use only Please arrange:  Doctor’s appointment  Heartguard appointment  Diabetic clinic appointment PTO  Respiratory clinic appointment  No further action needed  Smoking cessation advice given Other…………………………………………………………………………………………..