New Patient Health Questionnaire (Adult)

Your contact details
Title
Name*
First Names Surname
Previous Surnames
Date of Birth*
DD slash MM slash YYYY
Home Telephone*
Work Telephone
Mobile Telephone
Home Address (inc. flat number if appropriate)*
Postcode*
Email address*
Enter Email Confirm Email
Next of Kin
Name*
First Names Surname
Home Address (inc. flat number if appropriate)*
Contact Telephone Number
Relationship to you*
Information About You
What is your first language?*
Do you require communication assistance?
- Large Print
- British Sign Language
- Interpreter
If an interpreter is necessary, please inform us each time you book an appointment
Ethnicity*
- White British
- White Irish
- Black Carribbean
- Black African
- Asian Indian
- Asian Pakistani
- Asian Chinese
- White + Black Carribbean
- White + Black African
- White + Asian
- Prefer not to say
What is your height?*
What is your weight?*
What is your most recent blood pressure reading?
If you are unable to provide your blood pressure at this time, there a blood pressure monitors in the waiting areas of Queen Square Medical Practice and Caton Health Centre.
Pulse
Repeat Medication
Are you on any repeat medication?*
- Yes
- No
If you answered yes, you need to make an appointment with either an Advanced Pharmacist Practitioner or a GP to obtain your next prescription.

Smoking
Do you smoke?
- Yes
- No
If 'No', have you ever smoked?
- Yes
- No
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?
Would you like advice on giving up smoking?
- Yes
- No
Alcohol
1 drink = 1/2 pint of beer OR 1 glass of wine OR 1 single spirit
Do you drink alcohol?
- Yes
- No
If so, how many units per week?
How many units of alcohol do you drink on a typical day when you are drinking?
How often do you have a drink containing alcohol?
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?

Family History
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.
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Have you had a flu vaccination? If yes, please specify the date.
Have you had a pneumococcal vaccination? If yes, please specify the date.
Contacting You
Please consent to being contacted
- I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.
Signature
Date and signature
(you will be asked to sign this form when you visit the practice)
Consent*
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.
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- First Choice
- Second Choice
- Third Choice
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Your contact details