Download New Patient Health Questionnaire

FEMALE PATIENTS ONLY
Date of most recent cervical smear: ………………………………….
East Finchley Medical Practice
Result of most recent smear: ………………………………………….
New patient health questionnaire
Please give details of any complications in past pregnancies:
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.
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EMIS ACCESS
If you would like to access your repeat medication, book GP
appointments, and view your medical records online, then please
provide ID when handing in your registration, as we will need this to set
up your online account.
IMMUNISATIONS
Children aged 5 and under: Please bring your child’s Red Book with
you when you register, alternatively provide a list of immunisations.
ALLERGIES
If any, list here allergies to foods, medications, substances etc.:
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ETHNICITY
Please tick the ethnic group to which you belong.
[ ] White British
[ ] Indian
[ ] White Irish
[ ] Pakistani
[ ] Other White Background
[ ] Bangladeshi
[ ] Mixed White & Black Caribbean [ ] Other Asian Background
[ ] Mixed White and Black African
[ ] Caribbean
[ ] White and Asian
[ ] African
[ ] Other Mixed Background
[ ] Other Black Background
[ ] Chinese
[ ] I do not wish to disclose
If Other, please specify:………………………………………………………
Surname:
Forename:
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Date of Birth:
Marital Status:
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Home Telephone Number:
Mobile Telephone Number:
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Work Telephone Number:
Email Address:
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Your Height (in cms):
Your Weight (in kgs):
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Next of Kin Title, Full Name, Relationship & Telephone Number:
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Main Language spoken:
To which London Borough
does your address belong to?
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Do you wish to receive text/email notifications from us?
Yes [ ] No [ ]
(Please turn over)
SMOKING
Do you smoke?: Yes / No
If No, have you ever smoked?: Yes / No
If Yes, would you like help to stop smoking? Yes / No
If Yes, please contact one of the following pharmacies who provide
smoking support services:

Oakdale - 71 High Road, London N2 8AQ

Cootes - 166-168 High Road, London N2 9ED

Links - 129 East End Road, London N2 0SZ
ALCOHOL
(Please answer ALL 3 QUESTIONS) Tick as appropriate:
1)
How often do you have a drink that contains alcohol?
[ ] Never (0 points)
[ ] Monthly or less (1 point)
[ ] 2-4 times per month(2 points) [ ] 2-3 times per week (3 points)
[ ] 4+ times per week (4 points)
2)
How many standard alcoholic drinks do you have on a
typical day when you are drinking?
[ ] 0 drinks (0 points)
[ ] 3-4 drinks (2 points)
[ ] 7-8 drinks (4 points)
Is there any of the following in your immediate family?
Heart Disease? Yes / No Which family member?………………………..
(heart attacks, angina, etc.)
Stroke?
Yes / No Which family member?………………………….
Cancer?
Yes / No Which family member?.…………………………
Diabetes?
Yes / No Which family member?.…………………………
Asthma?
Yes / No Which family member?………………………….
High Blood Pressure?
Yes / No Which family member?..………………
Epilepsy or fits?
Yes / No Which family member?..………………
Nervous Disorders?
Yes / No Which family member?.........…………
Kidney Disease?
Yes / No Which family member?………………..
Depression?
Yes / No Which family member?………………………….
CARERS
Do you need / have anyone who looks after you or your daily needs as a
Carer? Yes / No
If yes, and you would like this person to deal with your affairs here,
please inform a member of the reception team.
Do you care for anyone else?
Yes / No (If “Yes”, ask the receptionist about Carers support)
3)
[ ] 1-2 drinks (1 point)
[ ] 5-6 drinks (3 points)
[ ] 10+ drinks (5 points)
How often do you have 6 or more alcoholic standard drinks
on one occasion?
[ ] Never (0 points)
[ ] Less than monthly (1 point)
[ ] Monthly (2 points)
[ ] Weekly (3 points)
[ ] Daily or almost daily (4 points)
TOTAL POINTS: ………………
The above equals one unit of alcohol. Using this information, on
average how many units of alcohol do you consume in one week?
TOTAL UNITS PER WEEK: ………….
MEDICATION
If you are currently taking any repeat medication, please provide your
repeat prescription slip form your previous GP so we can sync it with
our system.
Please select from one of our local pharmacies that you would like us to
send any prescriptions to:

CW Andrew - 32 High Road, London N2 9PJ
[ ]

Oakdale - 71 High Road, London N2 8AQ
[ ]

Cootes - 166-168 High Road, London N2 9ED
[ ]

Links - 129 East End Road, London N2 0SZ
[ ]
Otherwise please state a pharmacy that you would like to use below:
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(Please turn over)