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 takingAllergies (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
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
- 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?
NeverLess than monthlyMonthlyWeeklyDaily or almost daily
- How often in the last year have you been unable to remember what happened the night before because you have been drinking?
NeverLess than monthlyMonthlyWeeklyDaily or almost daily
- How often in the last year have you failed to do what was normally expected of you because of drinking?
NeverLess than monthlyMonthlyWeeklyDaily or almost daily
- 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?
NoYes, on one occasionYes, 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 bloodpressure and hand the print-outs to reception.
______
For office use only
Please arrange:
Doctor’s appointment
Heartguard appointment
Diabetic clinic appointment
Respiratory clinic appointment
No further action needed
Smoking cessation advice given
Other…………………………………………………………………………………………..
PTO