Download Health Questionnaire - Brookfield Park Surgery

Reviewed: January 2015
BROOKFIELD PARK SURGERY
NEW PATIENT REGISTRATION / HEALTH QUESTIONNAIRE
To register with the Practice please complete this questionnaire as fully as possible. The information
will help the doctor to make an initial assessment of your health which will help in your future
treatment.
Surname: ……………………………..… Forename(s): ………………………………… Title:…………
Address: …………………………………………………………………………………………………………..
……………………………………………………
Home tel: ……………………… Work:
Postcode: …………………
……………………..
Male / Female
Mobile:…………………….……….
Date of Birth: ………………………
Marital status: ….…………………………........
Occupation: ……………………………………
Weight (approx): ………………………Kg.
Height: ……………Ft……………Inches…………….
Blood Pressure:…………………………………
Borough & Country of Birth:………………………………Language spoken:………………………………
Ethnic Origin:…………………………………………
Interpreter required:
Yes / No
IF UNDER 16:
Name(s) of parent(s) / guardian(s):……………………………………………………………………………
Relationship to patient:…………………………………………………………………………………………
Name of School:…………………………………………………………………………………………………
IF OVER 16:
You are eligible for an HIV test. Would you like to have one?
Yes / No
If yes, please let one of the reception team know and advise them if you would prefer to have the test
at the Royal Free Hospital or the Whittington Hospital. They will fill out a blood test form for you. Take
it the hospital you have selected between 9am and 4.30pm, Monday to Friday, where they will take
blood for the test.
You are eligible for Sexual Health Testing. Would you like to have one?
If Yes, Please ask reception to book with Nurse
IF OVER 75:
You are eligible for a Health Check. Would you like to have one?
If Yes, Please ask reception to book with Doctor and HCA
Yes / No
Yes / No
NEXT OF KIN DETAILS:
Name:…………………………………………… Contact details:…………..………………………
Relationship to patient:…………………………………………………………………………………………
SMOKING
Do you smoke?
Cigarettes per day ……..
Cigars per day ..…..
Ounces of tobacco per day ……..
How old were you when you started smoking? …………………..
Yes / No
If Yes, how many:
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Reviewed: January 2015
EX-SMOKERS
How old were you when you stopped smoking? …………………
How much did you smoke per day? …………………………………..
PASSIVE SMOKING
Are you exposed to smoke at work?
Yes / No
At home?
Yes / No
DIET
Do you add salt to your food after cooking?
Yes / No
Do you have a varied diet including milk, meat, vegetables and fruit?
Yes / No
Has your Cholesterol been checked in the last 2 years?
Yes / No
EXERCISE
Do you take regular exercise?
Yes / No
If yes, what sort of exercise? …………………………………………………………………
How many times per week? …………………………………………………………………..
ALLERGIES
Are you allergic to any substances or foods? Yes / No
If yes, please give details:………………………………………………………………………………………
………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………..
ALCOHOL
Incorporating Alcohol Users Disorders Identification Test (AUDIT) C
Pint of Regular Beer/lager/Cider
Alcopop or Can of Lager
Glass of Wine (175 ml)
Single Measure of Spirits
Bottle of Wine
Questions
0
Never
1
Monthly
or less
=
=
=
=
=
2 UNITS
1.5 UNITS
2 UNITS
1 UNIT
9 UNITS
SCORING SYSTEM
2
3
2-4 times
2-3 times
per month
per week
How often do you have a drink
that contains alcohol?
How many standard alcoholic
drinks do you have on a typical
1-2
3-4
5-6
7-8
day when you are drinking?
How often do you have 6 or
Less
more standard drinks on one
Never
than
Monthly
Weekly
occasion?
monthly
How often in the last year have
Less
you found you were not able to
Never
than
Monthly
Weekly
stop drinking once you had
monthly
started?
How often in the last year have
Less
you failed to do what was
Never
than
Monthly
Weekly
expected of you because of
monthly
drinking?
Has a relative/friend/doctor/
Yes, but
health worker been concerned
No
not in the
about your drinking or asked
last year
you to cut down?
Scoring: A total of 5+indicates hazardous or harmful drinking
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4
4 + times
per week
10+
Daily or
almost
daily
Daily or
almost
daily
Daily or
almost
daily
Yes,
during the
last year
Your
Score
Reviewed: January 2015
MEDICATION
Please give details of any medication which you take (prescribed or otherwise):
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
Name of drug: ……………………………………
Dosage: …………………………………………….
FEMALE PATIENTS
Date of most recent cervical smear: …………………………Result?
Normal / Abnormal
Place of Procedure:........................................................................................
Please give details of any complications in pregnancy, miscarriages, terminations of pregnancy:
………………………………………………………………………………………………………………………
Which method of contraception are you using at present?.......................................................................
CARERS
Do you need / have anyone who looks after you or your daily needs as Carer?
If “Yes”, would you like them to deal with your health affairs here?
(the receptionist can help with these arrangements)
Do you care for anyone else?
If “Yes”, ask the receptionist about Carers support.
Yes / No
Yes / No
Yes / No
IMMUNISATION DATES FOR THE FOLLOWING:
Diptheria/Polio/HIB:
1st:………………2nd……………………3rd:…………………Booster:……...……….
Meningitis C:
1st………………..2nd:……………………
BCG:…………………………
Measles, Mumps, Rubella (German Measles):
1st:………………………Booster:……………………
or,
if given separately: Measles:……………………Mumps:……..……………….Rubella:……………………
Tetanus: ………………Typhoid:……………… Yellow Fever:………………… Cholera:…………………
Hepatitis A:
1st:………………2nd……………………3rd:…………………
Hepatitis B:
1st:………………2nd……………………3rd:…………………
Hepatitis C:
1st:………………2nd……………………3rd:…………………
Others:………………………………………………………………………………………………………………
PAST MEDICAL HISTORY
Please give details of any hospital treatment as an in-patient:……..………………………………………
………………………………………………………………………………………………………………………
Please give details of any treatment for any chronic medical conditions:………………………………….
………………………………………………………………………………………………………………………
Please give dates of any X-ray, MRI or CT scans, Mammogram, Ultrasound:……………………………..
………………………………………………………………………………………………………………………
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Reviewed: January 2015
FAMILY HISTORY
Is there any of the following in your family (father, mother, brother, sister) before age of 65?
Please Circle
Heart Disease (heart attacks, angina)
Yes / No Which family member? ………………………….
Stroke
Yes / No Which family member? ………………………….
Asthma
Yes / No Which family member? ………………………….
Diabetes
Yes / No Which family member? ………………………….
Cancer
Yes / No Which family member? ………………………….
Site of cancer ……………………………………
High Blood Pressure:
Yes / No Which family member? ………………………….
Tuberculosis
Yes / No Which family member? ………………………….
Other serious illness:
Yes / No Which family member? ………………………….
What illness?.....................................................................
Thank you for completing this questionnaire. Please book an appointment with HCA for New
Patient Health Check. After registering please ask the Reception to provide you with patient
online access details
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