New Patient Questionnaire New Patient Health Questionnaire for Adults Step 1 of 2 50% Your Contact DetailsTitle OptionalPlease SelectMrMrsMissMsName First Last Date DD slash MM slash YYYY Occupation Optional Contact NumberEmail Address Street Address Address Line 2 City County / State / Region Post Code Information About YouWhat is your height? What is your weight? What is your first language? Do you need an interpreter?Please SelectYesNoEthnic GroupWhitePlease SelectBritishIrishOtherUntitled BlackPlease SelectCaribbeanAfricanOtherUntitled Optional AsianPlease SelectIndianPakistaniChineseOtherUntitled Optional MixedPlease SelectWhite + Black CaribbeanWhite + Black AfricanWhite + AsianOtherUntitled Optional Previous GPName and Address of Previous GPProof of Identity and Address ProvidedPlease SelectBirth CertificateDriving LicencePassportUtility BillAllowance BookSolicitor's LetterOffer of TenancyOtherUntitled Optional Medical InformationPlease list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took placeHave you ever suffered from? (tick as appropriate)Epilepsy Yes No Heart Attack/Stroke Yes No High Blood Pressure Yes No Cancer Yes No Eczema/Hay Fever Yes No Blindness/Glaucoma Yes No Diabetes Yes No Depression Yes No Asthma Yes No COPD Yes No If yes, please state the year(s) when were you first diagnosed? Optional Please list any medicines being taken and the amount: OptionalAre you registered disabled? (If yes, please give details)Please SelectYesNoUntitled Optional Are you allergic to any medicines and if so, which?Please SelectYesNoUntitled Optional Have you ever refused treatment/screening of any kind and if so, what and when?Please SelectYesNo Have you ever suffered from? (tick as appropriate) Anxiety OptionalPlease SelectYesNoOCD OptionalPlease SelectYesNoDepression OptionalPlease SelectYesNoBipolar DisorderPlease SelectYesNoCarersDo you have a carer? (If yes please give details)Please SelectYesNoUntitled OptionalAre you a carer? (If yes please give details)Please SelectYesNoUntitledWillDo you hold a Living Will?Please selectYesNo(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness) WomenHave you ever had a cervical smear?(If 'yes', please state when, where and the result)Please SelectYesNoUntitled OptionalSmokingDo you smoke?Please SelectyesNoIf 'No', have you ever smoked?Please SelectyesNoIf you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? Would you like advice on giving up smoking?Please SelectYesNoAlcohol1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits 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?Please selectNeverLess than MonthlyMonthlyWeeklyDailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?Please selectNeverLess than MonthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking?Please selectNeverLess than MonthlyMonthlyWeeklyDailyIn 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 selectNoYes, on one occasionYes, more than once