New Patient Questionnaire(1) - Alford Medical Practice

New Patient Questionnaire(1) - Alford Medical Practice

ALFORD MEDICAL PRACTICE NEW PATIENT QUESTIONNAIRE Title DATE: Name Date of Birth Address Sex Home Telephone No Male Marital Status Contact N...

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ALFORD MEDICAL PRACTICE

NEW PATIENT QUESTIONNAIRE

Title

DATE:

Name

Date of Birth

Address Sex

Home Telephone No

Male

Marital Status

Contact No (if different)

Female

Married Single Divorced

Occupation

Widowed Separated Cohabiting

Are you a

Carer?

Main Care for Someone else

Who for?

Which ethnic group do you belong to? - You are not obliged to complete this section Please tick as appropriate White Scottish

Indian

Black Caribbean

White Irish

Pakistani

Black African

Other White British

Bangladeshi

Other Black Ethnic

Other White Ethnic

Chinese

Other Ethnic Mixed Origin

Other Asian Ethnic

Other Ethinc Group

I do not wish to give this information

Medical History Previous Serious Illnesses

Operations and Dates

Present regular medication (please list name, strength and how often taken) Name

Strength

Drug Allergies

ADDITIONAL INFORMATION REQUIRED - PLEASE SEE OVERLEAF

How often taken

NEW PATIENT QUESTIONNAIRE (cont'd) Family History Which of your blood relations have suffered from any of the following? Heart Disease

Cancer

Diabetes

High Blood Pressure

Asthma

Tuberculosis

Stroke

Other Serious Illness

Immunisations Which vaccinations have you had and when? Diptheria

Polio

German Measles

Tetanus

Typhoid

Measles

Cholera

BCG

Yellow Fever

Smoking Habits Smoker

Number of cigarettes/cigars per day

Ex-Smoker

Date Stopped

Number of cigarettes/cigars per day

Non -Smoker

Alcohol Intake Please estimate you alcohol intake per week (1 unit = half pint beer or 1 glass wine or 1 measure spirit Number of units per week

Exercise How many times per week do you exercise for 20 minutes or more?

FOR FEMALE PATIENTS ONLY Have you had any children?

Give Ages

Have you had a miscarriage or termination of pregnancy? Dates Which method of contraception are you using at present? When was your last smear test? Patient Signature

If not patient, please state relationship

DO NOT COMPLETE THIS SECTION Personal Details recorded

by

Medical History recorded

by

Lifestyle recorded

by