<p> BARNFIELD AND PARTNERS LORDSHILL HEALTH CENTRE</p><p>NEW PATIENT QUESTIONNAIRE</p><p>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.</p><p>NAME MR/MRS/MISS/MS/OTHER ETHNIC FIRSTLANGUAGE Refused ORIGIN</p><p>DATE OF BIRTH OCCUPATION</p><p>HOME PHONE NUMBER ………………………… NEXT OF KIN or CONTACTS IN AN EMERGENCY</p><p>MOB MOBILE …………………………………………….. Name </p><p>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 </p><p>ARE YOU A CARER? DO YOU HAVE A CARER? Please complete the carers form</p><p>DO YOU OR A CLOSE FAMILY MEMBER (Mother, Father, Brothers or Sisters) SUFFER FROM ANY OF THE FOLLOWING?</p><p>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</p><p>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</p><p>NON-DRUG ALLERGIES For example - nuts, tomatoes, animal fur. Yes or No</p><p>REGISTERED GP ………………………………………………………………………………… </p><p>APPOINTMENT MADE WITH GP or NURSE - date and time ……………………………… </p><p>Thank you for taking the time to complete this form; it will help us to help you.</p><p>MS Debra Charman Practice Manager</p><p>Office use Repeat Meds…. Photo ID …. Add ID ….. Ethnicity …. BP. Smoking Status ... Pat Sig.. . Next of Kin … Carer ….. Checked Page 2</p><p>ABOUT YOURSELF</p><p>Name ………………………………………………….. Date of Birth ……………………………</p><p>BP Reading ……………… Pulse ………….. Date taken ………………... </p><p>Please use BP machine in Reception</p><p>DO YOU SMOKE? Yes / No If yes how many Cigarettes per day …………………</p><p>(office use only) Are you an ex-smoker? Yes / No Quitters form given When did you give up ………………………………</p><p>WEIGHT HEIGHT</p><p>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</p><p>DIET GOOD AVERAGE LOW FAT HIGH FAT How would you describe your diet? POOR VEGETARIAN</p><p>ARE YOU CURRENTLY PREGNANT ? Yes No</p><p>If Yes, when is your baby due? …………………………………</p><p>Have you had your booking appointment? Yes No</p><p>ILLNESS</p><p>Have you had any illness or operations? If yes please give date and diagnosis/type of operation.</p><p>MEDICATION </p><p>Please list any regular medication that you are taking or give us a copy of your repeat order slip from your previous surgery</p>