Queens Walk Practice - New Patient Questionnaire

Please provide detailed information about yourself to enable us to provide the best care for you. All information will be kept strictly confidential.
Patient Information
Title*

MrMissMrsMsOther
NHS Number
If Known
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Previous Surname
Gender*

MaleFemaleOtherRather not say
Place of Birth*
Town & Country
Ethnicity*
If not born in the UK please state date of arrival

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Home Tel*
Work Tel*
Mobile Tel*
Email*
example@example.com
Previous GP*
Address while at previous GP*

Street Address

Street Address Line 2

CityCounty

Postcode
Marital Status*

SingleMarriedSeparatedCo-habitingWidowed
Occupation*
Religion*
Your next of kin or who you would like us to contact in an emergency
Name*

First NameLast Name
Relationship*
Tel Number*
Health Questions
Past/Current Medication History (if none please type N/A)*
Diabetes, heart disease, high blood pressure, asthma, stroke, TB, high cholesterol, epilepsy, mental illness, cancer ETC.
Any medication you're currently on? (if none please type N/A)*
Allergies medication or anything else? (if none please type N/A)*
Any hospital procedures/operations? (if none please type N/A)*
Have you had any immunisations? (if none please type N/A)*
Are you allergic to any drugs?*

YesNo
Please specify*
Are you allergic to anything else?*

YesNo
Please specify
Nominated pharmacy for EPS (if none please type N/A)*
What was the date of your last smear test?
If applicable
Where was it carried out?
What was the result?
What is your height?*
What is your weight?*
Have your ever smoked tobacco*

YesNo
Do you still smoke?*

YesNo
How many cigarettes per day did/do you smoke?*
How often do you have a drink containing alcohol?*

NeverMonthly or less2 - 4 times per month2 - 3 times per week4 + times per week
How many units of alcohol do you drink on typical day when you are drinking?*

1-23-45-67-910+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
About your family's health

Has anyone in your immediate family (ie. parents, siblings or grandparents) suffered from any of the following ilnesses? (if none then mark at least one box N/A)*

	Family Member	Age of onset	Comments
Diabetes
High Blood Pressure
Asthma
Heart Disease
Stroke
High Cholesterol
Mental Illness
Cancer - specify type in comments

Signature
Name*

First NameLast Name
Signature*

Clear
Date of birth*

DayMonthYear
Date
Should be Empty:

Patient Information

Health Questions