New Patient Questionnaire

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

What is your height? *

What is your weight? *

What is your first language? *

Do you need an interpreter? *

Yes No

Ethnic Group *

Do you attend any existing secondary care outpatient clinics or specialities?

Yes No

If yes, please state below

Please list any medicines being taken and the amount: (You will require a new patient appointment before any medications can be requested and prescribed) If you are on 6 or more prescribed items please request a double appointment.

Are you allergic to any medicines? *

Yes No

If so, please give details

Have you ever suffered from? (tick as appropriate)

Anxiety

OCD

Depression

Bipolar Disorder

If yes to any of these, please state the year(s) when were you first diagnosed?

Do you have any other mental health issues? *

Yes No

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Do you hold a Living Will? *

Yes No

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

Do you use a Vape or an Electronic device? *

Yes No

Do you consume alcohol? please pick from the dropdown *

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? *

Please 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. *

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

Which Pharmacy would you like your prescriptions to be sent to? *

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

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

Yes No

Signature *

Date *

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New Patient Questionnaire

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