Title: PATIENT QUESTIONNAIRE
Author: Preinstalled_user
Last saved by: BURTON, Tanya (WASHWAY ROAD MEDICAL CENTRE)
Company: Gateway

5. The information below may be important in identifying cause & prevalence of conditions which vary according to ethnicity and ensuring services are shaped to best meet the individual needs of all our patients.

ETHNICITY

This information may be important in identifying cause & prevalence of conditions which vary according to ethnicity.  Tick one box to indicate your ethnic group:
             
White 		Black Caribbean 		Indian

White British 		Black African			Pakistani 	

White Irish	Other Black background 		Bangladeshi

          Other ethnic group					Chinese

          Do not wish to state ethnicity                             Other Asian background

Other; please list.                   	

GENDER

Which of the following options best describes how you think of yourself?

	Woman (including trans woman)		Man (including trans man) 

Non-binary		In another way			Don’t want to say

Is your gender identity the same as the gender you were given at birth?	

        Yes		         No		     Don’t want to say

SEXUALITY

Which of the following options best describes how you think of yourself?

	Heterosexual/straight			Gay or lesbian

Bisexual				Other sexual orientation not listed

	Not sure				Don’t want to say

6.   For Women aged 25+ only:  

Date of last smear test: _________ Where? _________ Result:________

__________________________________________________________________________________
Working together    Thank you; we will review the information provided. Please sign to acknowledge your understanding & agreement to use our services as set out in our Practice leaflet v1.2:

Signed:  

NEW PATIENT QUESTIONNAIRE
                        	
Please answer each question as fully as you can. If you need help filling in this sheet, just ask one of our staff. This confidential information will be stored electronically & shared only for healthcare purposes.  

Please return this form to reception along with your GMS1 registration form, confirmation of ID & address & a list/re-order slip of repeat medication.

Office use only: ID checked:	   Address checked:       Rpt Rx appt:

1.	YOUR DETAILS 		Date you completed this form: ___________

Surname: ____________________	Forenames: ______________________
All Previous Surnames: _____________________________ Title: _____
Address:  ______________________________________________________
Postcode:  __________________	Date of birth: ______________________

Your telephone no’s (including mobile): _____________________________
We offer automatic text messaging for appointment & review reminders, please indicate your consent to this:      [  ] yes please;     no thanks [   ]  

Email address:_________________________________________________
We will use your email address to send you messages about your healthcare, please indicate your consent to this: [   ] yes please;  no thanks [   ]  

Emergency contact name & number _________________________________

Do you have any special information or communication needs?   	YES/NO

If interpreter needed, please state language:__________________________

State if other needs – e.g.: text relay service/SMS/email _________________

Are you a carer? 							YES/NO       
(i.e. do you care for a relative/partner/friend or disabled child on an unpaid basis)   

Are you permanently housebound?  					YES/NO
(ie unable to leave your bed to attend hospital or GP appointments]

Are you a military veteran?						YES/NO

2.	YOUR CURRENT STATE OF HEALTH – please answer each line

Have you ever been diagnosed with: | No | Yes | Tick below if you are currently taking medication for this**
Asthma | | |
Cancer | | |
COPD | | |
Depression | | |
Diabetes | | |
Epilepsy | | |
Glaucoma | | |
Heart disease | | |
Hypothyroidism | | |
High blood pressure | | |
Mental health | | |
Rheumatoid arthritis | | |
Stroke/TIA | | |
Please list any other serious or chronic illnesses, operations or disabilities:

** please attach a copy of your current medication re-order slip

If you’re currently taking prescribed medication, you will need to book an appointment with our practice pharmacist in the next 5 – 10 days & before you need your first prescription from us. We like patients to order their medication directly with us, online or in writing, so please bring formal photo ID to this appointment so we can set up online ordering for you.

If you take prescribed Contraception, please book an appointment with our Practice Nurse before your next supply is needed.

Do you suffer from any allergies or have had a reaction to any medication?                   
NO		YES 	    - please list these here:

3.	LIFESTYLE HABITS – please circle or complete each section

Height:      ft        ins   or             m  	Weight:        st        lbs   or            kg 

Exercise: - read about our Thursday walking group at www.wrmc.org.uk 
Number of times per week you engage in 30mins+ moderate activity? _______

Smoking Status:	

Never smoked tobacco  	   	Ex-smoker: I gave up in (year) ______
Current Smoker  - I currently smoke ________/day

Alcohol:   Current alcohol intake in units = __________/week

[1 drink unit = ½ pt Beer/lager/cider or small glass wine/sherry or 1 spirit measure]

How often do you have a drink containing alcohol?
Scoring System
0 | 1 | 2 | 3 | 4 | Your Score
Never | Monthly or Less | 2-4 times per month | 2-3 times a week | 4 + times per week |

How many units of alcohol do you drink on a typical day when you’re drinking?
0 | 1 | 2 | 3 | 4 | Your Score
1 - 2 | 3 – 4 | 5 – 6 | 7 – 8 | 10+ |

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
0 | 1 | 2 | 3 | 4 | Your Score
Never | Less than monthly | Monthly | Weekly | Daily or almost daily |

A total score of 5+ indicates increasing or higher risk drinking.  If this is the case, please make an appointment to see either our practice nurse, healthcare assistant or a doctor for advice and support on sensible drinking or help in reducing your intake; view more info at www.nhs.uk/livewell/alcohol 

4.	YOUR FAMILY HISTORY
 
If any of your immediate family were diagnosed with any of these illnesses before the age of 60, please tell us by ticking the appropriate box(es).  If none, tick here
| Mother | Father | Sisters | Brothers
Asthma | | | |
Diabetes | | | |
Stroke/TIA | | | |
Heart Disease | | | |
High Blood Pressure | | | |