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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: Page 1 of 4 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 Page 2 of 4 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:…………………………….. ……………………………………………………………………………………………………………………… Page 3 of 4 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 Page 4 of 4