Woodbank Surgery

0161 705 1630

New Patient Questionnaire Adults

Patient's Details

Title(Required)

Name

DD slash MM slash YYYY

Information About You

Do you need an interpreter?(Required)

What is your Ethnic Group

White(Required)
Black(Required)
Asian(Required)
Mixed(Required)

Medical Information

Have you ever suffered from: (Please tick as appropriate)
If yes to any of the above, please state the year(s) when you were first diagnosed?
Please list any medicines being taken and the amount:
Registered Disabled(Required)
Are you registered disabled? If yes please give details
Allergies(Required)
Are you allergic to any medicines and if so, which?
Refused Treatment(Required)
Have you ever refused treatment/screening of any kind? If so, what and when?
Medical History
Have you ever suffered from? (Please tick as appropriate)
If yes to any of the above conditions, please state the year(s) when you were first diagnosed?
Mental Health(Required)
Do you have any other mental health issues? (If yes, please give details)
Receiving Treatment(Required)
Are you receiving or have you received any treatment or therapy? (If yes, please give details of your care and when you received it)
Please list any serious illness/operations/disabilities (for women any pregnancy related problems) and the year they took place in the box below.
Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.
Carers(Required)
Do you have a carer? (If yes, please give details)
Carers(Required)
Are you a carer? (If yes, please give details)
Living Will(Required)
Do you hold a Living Will? (A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
Women - Cervical Screening
Have you ever had a cervical smear? (If yes, please state when, where and the result)
Smoking(Required)
Do you smoke?
Ex-Smoking
If No, have you ever smoked?
If you do currently smoke, how many cigarettes do you smoke per day?
Advice On Quitting Smoking
Would you like advice on giving up smoking?

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirit
Drinker/Non Drinker(Required)
Do you drink Alcohol?
MEN : How many units of alcohol do you consume per WEEK?
WOMEN : How many units of alcohol do you consume per WEEK?
Advised To Cut Down
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
For patients aged 65 or over or those with a chronic disease (e.g. asthma or diabetes)(Required)
Have you ever had a flu vaccination?
Please give date
Pneumonia Vaccine(Required)
Have you had a pneumococcal vaccination?
Please give date
Please give name, address, telephone number and relationship of next of kin.
Please print name