New Patient Health Questionnaire (patients 16yrs & over)

TO BE COMPLETED FOR ALL PATIENTS 16 YEARS & OVER To enable us to provide continuation of care, it is important that we obtain certain information which enables us to do this safely and effectively.

Last Updated: 25/02/2023

*** IMPORTANT NOTICE ***

We WILL NOT issue repeat medication upon registration. You will need to obtain AT LEAST 28 DAYS supply of any repeat medication from your current GP BEFORE you register with us.

I understand that I cannot order repeat medication for the first 28 days of registration and confirm the following *

I have already obtained 28 days supply of medication from my current GP

I do not require any repeat medication for at least the next 28 days

I do not take any repeat medication

Patient Details

Full Name *

Date of Birth *

Address *

Gender *

Marital Status *

Please confirm a NEXT OF KIN/EMERGENCY CONTACT (Full name & relationship to you)) *

Please confirm your NEXT OF KIN/EMERGENCY CONTACT Telephone number *

Contact

By adding a mobile contact we will automatically assume that you consent to receiving appointment reminders and invites by SMS. ** to opt-out of this, please download the appropriate form in the 'forms' section. By adding an email address you will automatically be given core online access to your medical record which includes booking appointments and ordering repeat medication. If you require full access, please download the appropriate form in the 'forms' section

** IMPORTANT - Accessible Information Standard

Ethnicity

Please select *

State Main (first) Language *

Do you require an Interpreter? *

Yes No

General Health Status

If you do not have a up-to-date Height, Weight, BMI & BP you can attend the surgery and use our Health Monitor in the patient area

Height in CENTIMETERS

Weight in KILOS

BMI

Blood Pressure

Pulse rate

do you have any health concerns at the moment that you have not previously disclosed to your GP? *

Yes No

If yes, please specify

** FEMALES 24YRS & OVER **

Cervical Smear Status

Have you had a Cervical Smear in the past?

Yes No

If YES, what was the date of your last smear?

Is there any reason why you do not/should not have a cervical smear? *

Yes No

If YES, please give details:

Family History

Is there any of the following in your family (father, mother, brother, sister) before age of 65?

Heart Disease (heart attack/angina)

Stroke

Cancer

Hypertension

Diabetes Type 1

Diabetes Type 2

Other

If you have selected any of the above, please specify the condition, family member & age at diagnosis if known

Smoking Status

Alcohol Status

*Approx guide - beer/lager (1/2 pint) = 1 to1.5 units, bottled lager/cider (330ml) = 1.7 units, wine (standard glass) = 2 units, spirits (single measure) = 1 unit

Are you Tea total? *

Yes No

if no, How often do you drink alcohol? *

How many units of alcohol do you drink on a typical day when you have a drink? *

For the following questions please indicate the answer which best applies

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

men - how often do you have 8 or more units of alcohol on one occasion?

women - how often do you have 6 or more units of alcohol on one occasion?

BOTH - in the last 12 months has a relative or friend, doctor or health worker had a concern about your drinking? or suggested you cut down? *

Yes No

Diet & Exercise

do you add salt to your food after cooking? *

Yes No

Do you have a varied diet including milk, meat, vegetables & fruit? *

Yes No

Has your cholesterol been checked in the last 2 years? *

Yes

Not sure

Do you take regular exercise? *

Yes No

If yes, what sort of exercise?

How often?

Current Medication

We send ALL our prescriptions electronically to a nominated Pharmacy of your choice. Please specify which Pharmacy you would like this to be sent to (please note. you can change this at any time)

Nominated Pharmacy (specify name and location) *

Please tell us if you are currently taking medication. Specify name of drug & dosage

Allergies

Do you have any current Allergies? *

Yes No

If yes, please specify

Immunisations

DTP/Polio/HIB

1st MMR

2nd MMR

Last Tetanus Vaccination

PNEUMOCCOCAL VACCINATION

SHINGLES VACCINATION

Any Travel Vaccinations & dates (eg. Hep A, Hep B, Typhoid, Yellow Fever)

Past Medical History

Please give us details of any current medical conditions or recent treatment or investigations that you have undergone along with the relevant dates.

Current Medical Conditions

Recent hospital admissions/treatment

Recent investigations (eg. x-ray, MRI, CT, ultrasound)

Carers

Does anyone look after you and your daily needs as a carer?

Yes No

If YES please provide the full name of your carer

Are you a Registered Carer? *

Yes No

If YES, please tell us the full name of the person you care for

Do you care for anyone else as a carer in a non-registered capacity?

Yes No

If YES, please tell us the full name of the person you care for

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE

To enable us to complete your registration, you must complete and submit the New Patient Registration Form (GMS1). This can be found on the NEW PATIENTS section of our website ** Please note: you will not be registered until we receive this !!

Please confirm that you have completed and submitted the New Patient Registration Form (GMS1) *

Yes No

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New Patient Health Questionnaire (patients 16yrs & over)

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