New Patient Questionnaire V2

This questionnaire provides us with some background on your current health. Please make sure you fill in all questions.

Last Updated: 22/06/2023

Your Contact Details

Title *

Full Name *

Date of Birth *

Previous Surname (e.g maiden name)

Main Telephone Number *

Alternate Number *

Email Address *

How can we contact you? *

Mobile

SMS

Landline

Post

Information About You

Occupation

Those who work will most likely spend the majority of their time in this environment therefore its important to know what you do. Your job description can give clinicians an idea of how psychically, mentally, and emotionally challenging your job is. If you are a carer please ask reception for a Carers Pack.

Current employment status? *

Please state your job title *

Are you a student? *

Yes No

If you are a student, where do you study?

Are you a carer? *

Yes No

If yes please give details

Do you have a carer? *

Yes No

If yes please give their details

Lifestyle

Please tell us your height *

Please tell us your weight *

How would you describe your diet? *

Good

Average

Poor

Smoking status

There are many ways to quit smoking, why not make an appointment with our HCA who can offer advice and support to help you quit?

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you used to smoke how long ago did you quit? *

If you do currently smoke, how many cigarettes or grams of tobacco do you smoke per week? *

Do you use an electronic cigarette? *

Yes No

Would you like advice on giving up smoking? *

Yes No

Alcohol

Do not forget that alcohol contains calories. Regularly drinking more than recommended can have a noticeable impact on your waistline. Try to keep to the recommended daily alcohol limits to reduce the risk of serious problems with your health, including risks to your heart health.

How often do you have a drink containing alcohol? *

How many units will you have on a typical day when drinking? *

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? *

How often in the last year have you found that you were unable to stop drinking once you started? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

How often in the last year have you needed a drink in the morning to get yourself going after a heavy drinking session? *

How often in the last year have you had a feeling of guilt or remorse after drinking? *

How often during the last year have you been unable to remember what happened the night before because of drinking? *

Have you or someone else been injured as a result of your drinking? *

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? *

Medical History

A family medical history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and diabetes. These complex disorders are influenced by a combination of genetic factors, environmental conditions, and lifestyle choices.

Womens health - if you have had your smear done abroad in the last 3 years please send your result to capccg.woodlands@nhs.net

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Registration Checklist

All online forms need to be completed, the surgery may reject your registration if any sections are incomplete.

Have you completed the Pre-Registration form? *

Yes No

Have you completed the Sharing Consent form? *

Yes No

Please make sure that all three forms are completed. The surgery may reject any incomplete applications. *

I understand my registration may be rejected if I do not complete all forms

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New Patient Questionnaire V2

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