Online Medical Questionnaire For New Patients Your Contact DetailsTitleSelect…MrMrsMissMsMxRather Not sayName First Last Date of Birth DD slash MM slash YYYY Occupation Address Street Address Address Line 2 City Post Code Contact NumberEmail Enter Email Confirm Email Information About YouWhat is your height? What is your weight? What is your first language? Do you need an interpreter?Please SelectYesNoEthnic GroupWhat Ethnic group to you most closely identify with? White Black Asian Mixed White British Irish Other Black Carribean African Other Asian Indian Pakistani Chinese Other Mixed White + Black Caribbean White + Black African White Asian Other Previous GPName and Address of Previous GPProof of Identity and Address Provided Birth Certificate Driving Licence Utility Bill Allowance Book Solicitor’s Letter Offer of Tenancy Medical InformationPlease list any serious illnesses / operations / disabilities (and for women, any pregnancy-related problems) and the year they took placeHave you ever suffered from? (tick as approriate)Epilepsy Yes No Blindness/Glaucoma Yes No High Blood Pressure Yes No Diabetes Yes No Heart Attack/Stroke Yes No Depression Yes No Cancer Yes No Asthma Yes No Eczema/Hay Fever Yes No COPD Yes No If yes, please state the condition and year(s) when you were first diagnosed?Are you currently on any medication? Yes No Please list any medicines being taken and the amountAre you registered disabled? Yes No Please give detailsAre you allergic to any medicines? Yes No Please give detailsHave you ever refused treatment/screening of any kind? Yes No Please give detailsHave you ever suffered from? (tick as appropriate)Anxiety Yes No Depression Yes No OCD Yes No Bipolar Disorder Yes No If yes to any of these, please state the year(s) when you first diagnosed?Are you receiving or have you received any treatment or therapy? Yes No Please give details of your care and when you received itDo you have any other mental health issues? Yes No If yes, please give detailsCarersAre you a carer? Yes No If yes, please give detailsDo you have a carer? Yes No If yes, please give detailsWillDo you hold a Living Will Yes No (A living Will us a documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)WomenHave you ever had a cervical smear? Yes No If yes, please state when, where and the resultGive details and when these issues aroseSmokingDo you smoke? Yes No If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? If no, have you ever smoked? Yes No Would you like advice on giving up smoking? Yes No AlcoholI unit = half a pint of beer, larger or cider. 1 units = a small glass of wine or 1 standard measure of spiritMEN: 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?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you failed to do what was normally expected of you because of drinkingNeverLess than monthlyMonthlyWeeklyDaily or almost dailyIn 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? Yes No Family HistoryPlease state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.Next of KinPlease give their name, address, telephone number and relationship of next of kinFor patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)Have you had a pneumococcal vaccination? Enter date or 'never'. Have you had a flu vaccination? Enter date or 'never'. Contacting YouI agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. I agree that I may be contacted OptionalSignatureYou will be asked to sign this when you visit the practiceDate Day Month Year