Jaunty Springs Health Centre - Medical Questionnaire

Personal Information
Name*

TitleForename/sSurname
Preferred NamePrevious Name
Date of Birth*

DayMonthYear
NHS Number (if known)
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Ethnicity*
Parents/Guardian
Name

First NameLast Name
Name

First NameLast Name
Relationship to child
Relationship to child
Please confirm that you hold parental responsibility for this child

I confirm
Please confirm that you hold parental responsibility for this child

I confirm
Contact Number
Contact Number
Contact Details
Home Number
Mobile Number*
Work Number
Email*
Preferred method of communication*

PhoneTextEmailPost
Do you consent to the receipt of text messages and emails in relation to your medical care, i.e. appointment reminders, test results, information regarding flu clinics or other clinic relevant to your medical care?*

YesNo
Armed Forces
Have you either served in the UKarmed forces and/or been registered with a Ministry of Defence GP in the UK or overseas (this includes regular, reservist, veteran, or family member)?*

YesNo
Gender Identity
Gender*

MaleFemale
Is your gender identity the same sex as you were assigned to at birth?

YesNo
Which of the following best describes how you think of yourself?

MaleFemaleNon-Binary/Prefer to self-describe
Language, Communication and Accessible Information
Main Language*
Do you require a language interpreter?*

YesNo
Do you have any hearing difficulties?*

YesNo
Do you require a BSL interpreter?*

YesNo
Do you consider yourself to have a disability or neuro diversity?*

YesNo
If yes, please provide details below:
Are there any reasonable adjustments our team could make to help when you visit our surgeries?
Carers
Do you have a carer?*

YesNo
If you have answered yes, our team will be in contact with you to obtain some further information. If you would prefer, we contact your carer directly for this please provide their contact details below:
Are you a carer?

YesNo
Next of Kin
Name*

First NameLast Name
Relationship to you*
Contact number*
Address*
Please be aware - next of kin information is held only for use in a critical emergency only.
Smoking Status
Have you ever smoked?*

Never smokedSmokerEx-smokerOther use of tobacco (e-cigarette, gum, patches etc.)
If you answered smoker, ex-smoker or other use of tobacco please provide details on how much you smoked per day?
If you are a current smoker, would you like our team to contact you regarding stopping smoking?

YesNo
Height and Weight
Height
e.g. 5 ft 6 in
Weight
e.g. 75kg
Alcohol Intake
On average how many units of alcohol do you consume per weel? You can use the picture below to calculate the units.
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
How often during the last year have you failed to do what was normally expected from you because of your drinking?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

NoYes, but not in the past yearYes, during the last year
Do you have concerns about your alcohol intake that you wish to discuss with a member of our team?
Medical History
Do you have or have had any of the following if yes please provide the us with as much information on the condition as you can – Date of diagnosis, treatment/medication taken.

AsthmaHypertension (High blood pressure)DiabetesStroke, mini-stroke, TIA, Cerebrovascular accidentRheumatoid ArthritisCancerEpilepsyGenetic condition or disorderDementiaOperationsMental HealthOther
Medications
Please list below any medications and doses that you are currently taking – please specify if these are currently provided these from a hospital
Please be aware, if you do take prescribed medication you will need to book an appointment with a GP before anymore can be prescribed. Appointments can be booked up to two weeks in advance. It takes three working days from medications being ordered before you can collect, please therefore you have an adequate supply of your medications.
Allergies
Please state below any allergies you have, please include food and drug allergies, including the reaction that you have had in the past.
Hospital Care
Are you currently receiving care from a hosptial consultant?

YesNo
If yes please provide the name, hospital address and speciality of the consultant you are currently under as well as any other contact details you have for their team:
National Screening
Date of last cervical screen (smear) if known

DayMonthYear
Date of last mammogram (breast screen) if known

DayMonthYear
Identification Verification
We require one document to confirm proof of name this can be any of the following:
- Birth Certificate
- Marriage Certificate
- Driving Licence (Valid)
- Passport (Valid)
- Deed Poll
We require one document to confirm proof of address:
- Utility Bill
- Council Rent Book
- Bank Statement
- Credit Card Statement
- Letter from Benefits Agency
Please Note:
- We ask all new patients to present the surgery with documentation to verify their identity.
- None of your verification documents are held on your records and are used for registration purposes only.
Should be Empty:

Personal Information

Parents/Guardian

Contact Details

Armed Forces

Gender Identity

Language, Communication and Accessible Information

Carers

Next of Kin

Smoking Status

Height and Weight

Alcohol Intake

Medical History

Medications

Allergies

Hospital Care

National Screening

Identification Verification