Download New Patient Health Questionnaire Adult

WESTWOOD MEDICAL CENTRE
New Patient Health Questionnaire for Adults
Your Contact Details
Mr  Mrs  Miss  Ms  Other 
Surname
Date of Birth
First Names
Occupation
Previous Surnames
Home Address
Postcode:
Home Tel
Mobile
Work Tel
Email
Fax
Alternative Communication Format –
Preferred Contact Method – Please tick one box
No Preference 
Home tel. number 
Work tel. number 
Mobile tel. number 
Email address 
Letter to home address 
Letter to temporary address 
Fax number 
What is your first language?
Ethnic Group
White
British

Irish

Other
 Please State:
Black
Caribbean

African

Other
 Please State:
Asian
Indian

Pakistani
Other  Please State:

Chinese
Mixed
White + Black  Caribbean White + Black African 
White + Asian  Other  Please State:

Information About You
What is your height?
What is your weight?
Blood Pressure?
Medical Information
Please list any serious illnesses / operations / accidents / disabilities and
for women any pregnancy related problems) and the year they took place:
Have you ever suffered from? (tick as appropriate)
Epilepsy
High Blood Pressure
Heart Attack/Stroke
Cancer
Eczema/Hay Fever
Mental Illness
Yes
Yes
Yes
Yes
Yes
/
/
/
/
/
No
No
No
No
No
Blindness/Glaucoma
Diabetes
Depression
Asthma
COPD
Yes
Yes
Yes
Yes
Yes
Please list any medicines being taken and the amount:
Are you allergic to any medicines and if so, which?
Yes / No
Carers
Do you have a carer? (If yes please give details) Yes / No
Are you a carer? (If yes please give details) Yes / No
Women
Have you ever had a cervical smear?
(Please state the last date)
Yes / No
/
/
/
/
/
No
No
No
No
No
Smoking
Do you smoke?
Yes / No
If 'No', have you ever smoked?
Yes / No
If you do currently smoke, how many cigarettes or ounces of tobacco do you
smoke per week?
Would you like advice on giving up smoking?
Yes / No
Alcohol
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
Never 
Less than Monthly 
Monthly 
Weekly 
Daily 
How often during the last year have you been unable to remember what happened
the night before because you had been drinking?
Never 
Less than Monthly 
Monthly 
Weekly 
Daily 
How often during the last year have you failed to do what was normally
expected of you because of drinking?
Never 
Less than Monthly 
Monthly 
Weekly 
Daily 
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?
No 
Yes, on one occasion 
Family History
Yes, more than once 
Relative
Heart disease/angina (over 60)  .......................................
Heart disease/angina (under 60)  ......................................
Stroke  ..............................................................
High blood pressure  .................................................
Diabetes  ............................................................
Asthma  ..............................................................
Cancer (type)  .......................................................
Mental illness  ......................................................
Next of Kin
Please give relationship, name, address and telephone number of next of kin
SUMMARY CARE RECORD
Patient
Name…………………………………………………………………………………………………………
………………….
NHS
Number………………………………………………….
Birth……………………………………………………..
Date
of
WESTWOOD MEDICAL CENTRE offers its patients the choice of having a Summary Care Record.
The new NHS Summary Care Record is being introduced to help deliver better and safer care and give
you more choice about who you share you healthcare information with.
WHAT IS THE NHS SUMMARY CARE RECORD?
The NHS Summary Care Record will contain basic information introduced to help about any allergies
you may have, unexpected reactions to medications and any prescriptions you have recently
received. The intention is to help clinicians in Accident and Emergency departments and ‘Out of Hours’
health services to give you safe, timely and effective treatment.
Clinicians will only be allowed to access your record if they are authorized to do so and, even then, only
if you give your express permission. You will be asked if healthcare staff can look at your Summary
Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. You
can refuse if you think access is unnecessary.
CHILDREN UNDER THE AGE OF 16
Patients under 16 years will not receive this letter, but will have a Summary Care Record created for them
unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please
either make this information available to them or decide and act on their behalf.
You do not have to have a Summary Care Record, although you are strongly recommended to consider
this choice. If you decide to proceed, but at any time in the future you, or a child you are responsible for,
change your mind and choose not to have a Summary Care Record, all you need do is to write to your
surgery informing them of you decision to “Opt-out”. If you have already told your Surgery that you
wish to “Opt-out” and you wish this to remain in place you need take no further action.
PLEASE TICK BOX ONLY IF YOU DO NOT WANT A SUMMARY CARE RECORD:
NO I would not like to have a Summary Care Record
If you want a Summary Care Record you do not have to do anything, it will automatically be created
for you.
If you are Opting Out of having a Summary Care Record please sign below.
Signed by Patient…………………………………………………………………………………………..