Download New Patient Health Questionnaire

RIVERSIDE SURGERY
Barnard Avenue, Brigg, DN20 8AS
NEW PATIENT HEALTH QUESTIONNAIRE
Title: Mr, Mrs, Miss, Ms: …………………..
Date of birth: ……………………………………….....
First names: ………………………………….…. Surname: ……………………………………..………….
Home Address:
Home Tel: ……………………………………………….
………………………………………………………..
Work Tel: ………………………………………………
………………………………………………………..
Mobile: ……………………………………………………
Postcode: …………………………………………
Email Address: …………………………………………
Are you happy to receive text messages
from the surgery?
Please state Yes or No:
………………………………
Occupation: …………………………….……...
Previous surnames: …………………………………..
(If applicable)
School/College:
(If school please state which school)
Are you registering with a GP for the first
time?
……………………………………………………….. Yes or No (please state): ……………………………….……..
If you are registering for the first time
you will need to provide a valid
passport or driving licence and a utility
bill from your place of residence.
Please give details of your previous GP
(STAFF USE ONLY)
Passport provided: Yes or No: ………..
Practice Name: ………………………………..
And
Utility Bill provided: Yes or No: ………..
(If applicable)
Dr Name: ……………………………………….
Address: ………………………………………….
……………………………………………………….
Postcode: …………………………………………
Telephone: ……………………………………….
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November 2016
ETHNIC GROUP – please circle which one applies to you
White European
Black Caribbean
Asian Indian
Irish
African
Pakistani
Chinese
Other:(please state):
………………………………………………………………………………………………………………….…
Main spoken language: (please state):
Interpreter Required?
……………………………………………………….
Yes or No: ……………………………………..
PERSONAL MEDICAL HISTORY
Height: …………………………………………..
Weight (approx): ……………………………….
Do you suffer from the following: Please state Yes or No
Heart disease: ………………………………..
Hypertension: …………………………………………
Diabetes: ………………………………………
Asthma: ……………………………………………….
COPD: ……………………………………………
Are you allergic to anything?
(example medication or other)
Please state: …………………………………..
If yes please list your allergies:
……………………………………………………….……
…………………………………………………………….
Please list any serious illnesses/operations/accidents/disabilities (and for any pregnancy
related problems) and the year they took place:
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
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November 2016
PERSONAL MEDICAL HISTORY CONTINUED
Are you currently receiving any hospital
care?
Any previous surgical procedures?
Please state: …………………………………..
Please state: …………………………………..
…………………………………………………...
…………………………………………………....
…………………………………………………...
…………………………………………………....
FAMILY HISTORY
Please state any serious illness, in
particular heart disease, strokes, high ……………………………………………………………
blood pressure, diabetes or any
inherited disease.
……………………………………………………………
Is there a family history of bowel/breast, ……………………………………………………………
prostate or any other recurring cancer.
……………………………………………………………
Please state relationship and age:
……………………………………………………………
MEDICATION
Please supply a copy of your current repeat prescription – no medication will be
given without evidence and authorisation from the GP.
(Medication takes 1 week to process)
Please list any medication and the dose that you are currently taking:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
ALCOHOL
Please take a few moments to complete our alcohol form attached to this registration
form.
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November 2016
SMOKING
Do you smoke?
Please state:
……………………
Have you ever smoked?
Please state:
……………………
When did you give up?
Please state:
……………………
If yes, please state how many a day:
Cigarettes
…………………………………………………………………..
Rolled tobacco
…………………………………………………………………..
Cigar
……………………………………………………………….….
Pipe
……………………………………………………………….…..
Electronic Cigarette …………………………………………………………………...
WOMEN
Have you ever had a cervical smear?
Please state:
If YES please detail when and where:
……………………………………………………….
……………………………………………………………
……………………………………………………….
……………………………………………………….
CONTRACEPTION
Are you prescribed any method of Please state what type:
contraception?
……………………………………………………………
Please state: …………………………………………
Would you like information about FOR STAFF USE ONLY:
contraception to be sent to you?
Information sent to patient: ………………….
Please state: ………………………………………….
SUMMARY CARE RECORDS (SCR) – sharing of medications, allergies
and adverse reactions
The information your doctor holds may be used by secondary care if you do not wish
this to happen you will need to complete an opt out form which is available at
reception or on our website:
www.riversidesurgerygps.co.uk
Your data will not be shared with any other third party.
Please sign to accept.
Signed: ……………………………………………
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November 2016
Date patient completed this form:
Patient signed:
…………………………………………………………..
………………………………………………………
YOUR ACCESSIBLILITY NEEDS
We want to get better at communicating with our patients. We want to make sure you
can read and understand the information we send you. If you find it hard to read our
letters or if you need someone to support you at appointments, please let us know.
Please tell us what your communication requirements are (eg, braille, large print ect)
Please state: ………………………………………………………………………………………………………..
Please tell us what communication requirements you have ()
RESEARCH
We are a Research Practice; if you are interested in participating in any of our clinical
trials please state Yes or No:
…………………………………………………………………………………………………………………………..
Please note it may take up to 7 working days to process your application form
FOR STAFF USE ONLY
New Patient questionnaire information
entered on to Emis Web
Date Entered on: …………………………..
Patient No: ……………………..
By Who: ………………………………………
Thank you for completing this questionnaire
Welcome to Riverside Surgery
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November 2016