New Patient Questionnaire for Adult

Please be advised that it can take a considerable time for your medical records to reach us. The information required in this form is required in order to help us better facilitate your immediate needs and will be treated with the strictest confidence.

New Patient Supplementary Questionnaire
Please use format day/month/year e.g. 12/05/1979
Gender
Carer
Are you a carer?
Please enter details for all members of the household including: Names, ages, and relationships
Please detail as much of your medical history that you feel will help us better facilitate your immediate medical needs. Include: previous serious illnesses and dates of significant operations
Please detail any current medication that you are currently prescribed including: name, dosage, and how often taken
Please list any drug allergies that you have
Please let us know of anyone in your family for whom has a history of: Heart disease, Stroke, Cancer, or diabetes
Smoker?
How many cigarettes do you smoke in a day? If you are an ex smoker how many cigarettes did you smoke in a day?
Estimated alcohol intake per week (1 unit = ½ pint of beer or 1 glass of wine or 1 measure of spirit)
How many times per week do you exercise for 20 minutes or more?
Any other information that will help to better inform the GP of your medical needs?
GP’s name and the name and address of your previous GP medical practice
Consent to contact your previous medical practice
We will have to contact your previous medical practice in order to have an up-to-date record of your current medical needs. Please indicate your consent for us to do this
Consent