New Patient Questionnaire v2

Confidential Personal Health Questionnaire for new registered patients aged 14+ (to be completed or in the case of person under 16 years of age on behalf of, each new patient of this practice

Last Updated: 11/07/2024

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984
    Marital status (optional)

  • Information About You

    Ethnic Group
    Do you need an interpreter?
    Are you a Military veteran (optional)

  • Smoking

    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking?

  • Alcohol

    How Many Units are in your Drink?

    A strong beer/lager (5.2% ABV) = 3 Units

    1 Medium glass of wine (12% ABV) = 2 Units

    1 Single measure of spirits (40% ABV) 1 Unit

    1 Bottle of Alcopop (5% ABV) - 1.4 Units

    1 Bottle of Wine (13.5% ABV) = 10 Units

     

    How many UNITS of alcohol do you drink on a typical day when you are drinking? (optional)
    How often have you had 6 (female) or 8 (male) units on a single occasion in the last year? (optional)

  • Alcohol continued

    If your total score for the above three questions is more than 5, please continue the questionnaire below

    How often in the last year have you have found you are not able to stop drinking once you had started? (optional)
    How often in the last year have you failed to do what was expected of you because of drinking? (optional)
    How often in the last year have you needed an alcoholic drink in the morning to get you going? (optional)
    How often in the last year have you had a feeling of guilt or regret after drinking? (optional)
    How often in the last year have you not been able to remember what happened when drinking the night before? (optional)
    Have you or someone else been injured as a result of our drinking? (optional)

  • Medical Information

    Do you have any of the following conditions? (optional)
    Is there any history of disease in your family
    Do you have a special diet (optional)

  • Carers

    Do you have a carer?
    Are you a carer?

  • 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.

  • Proof of Identity and Address Provided

    Two items required and must be one from each section (Same proof CAN NOT be used for both sections)

    Please bring proof of ID to receptionat Cropredy Surgery

    Identity Document Type 1
    Identity Document Type 2

  • Date

    Date
    For example, 15 3 1984
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.