New Patient Questionnaire

This is for patients who are 16 and older

Last Updated: 11/12/2023

Your Contact Details

Information about you

What is your first language? *

Do you need an interpreter? *

Yes No

Height

Weight

Medical History

We require full access to your records and also permission to share your records with other health care providers under the NHS umbrella to be able to provide you with our services.

Family History

Has anyone in your family been diagnosed with one of the following? *

Heath Attack

Stroke

Diabetes

Mental Illness

High Blood Pressure

Asthma

Eczema

Cancer

Epilepsy/Fits

If you clicked any of the above, please state the relation you have with this person, and when they were diagnosed. (If they've had cancer, please state what type.)

Next Of Kin

Patient's Next of Kin's Name

Their Relationship To You

Their Address

Their Contact Number

Carer Information

Are you a carer? Do you look after someone who relies on you for support? *

Yes No

Who do you care for?

Do you have a carer? *

Yes No

Carer's name

Carer's Address

Carer's Contact Number

Smoking

Have you ever smoked? *

Yes No

Do you still smoke?

Yes No

If yes, how many do you smoke per day?

If no, when did you give up?

Would you like help to stop?

Yes No

Alcohol

Remember:

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirit

Exercise

Do you take regular exercise? *

Yes No

If yes, what sort of exercise?

How many times per week?

Signature

Signature *

HAVE YOU COMPLETED THE NEW PATIENT REGISTRATION FORM? YOU WILL FIND THE FORM FROM THIS WEBSITE *

Yes No

Date *

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New Patient Questionnaire

Further Information