New patient health questionnaire

Last Updated: 14/11/2024

  • PATIENT DETAILS

    Date of Birth
    For example, 15 3 1984
    Do you require a translator (optional)
    Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccination reminders, to let you know that your prescription or your sick note is ready for collection and anything else relevant to your healthcare?
    We have an electronic method of contact available for patients to contact the surgery for non-urgent requests – do you consent for us to correspond with you via this method and supply us with a preferred e-mail address for this purpose?
  • Asylum Seeker or Refugee

    Are you an Asylum Seeker or Refugee ? (optional)
    Please state the date that you first entered the UK (optional)
    For example, 15 3 1984
  • Lifestyle - Smoking

    ADVICE: If you smoke, please see www.helpmequit.wales stop smoking advice and support

     

    Do you smoke (optional)
  • Lifestyle - Alcohol

    For the following questions please answer to the best of your knowledge:  We have provided a basic guide to alcohol content below to assist your completion:

    • A pint of 5.2% strength lager/beer/cider contains 3 units   
    • A standard 70cl bottle of spirits contains 28 units
    • A standard (175ml) glass of wine contains 2 units        
    • A single small shot of spirits (25ml) contains 1 unit
    • A pint of 3.6% strength lager/beer/cider contains 2 units  
    • A 750ml bottle of wine contains 10 units                            

    Follow the link below to access more information including a guide to calculating your alcohol intake - Alcohol units - NHS (www.nhs.uk)

    Or you can use Alcohol Change’s calculator - https://alcoholchange.org.uk

    ADVICE: If you are consuming over 14 units per week, please see www.drinkaware.co.uk for alcohol consumption advice

  • Lifestyle - Height/Weight

    ADVICE: Please calculate your BMI at 111.wales.nhs.uk/LiveWell/BMIcalculator/

    If your BMI is under 18.5 and over 24.9, please see 111.wales.nhs.uk/livewell for lifestyle advice

  • Next of Kin

    (to be contacted in an emergency)

  • Family History

    NB: The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records.

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

  • Current medication list

    Please give details of any medication which you take (prescribed or otherwise):

    Please forward us your most recent repeat medication slip if you have one.Send it to prescription.w97028@wales.nhs.uk

  • Allergies

  • Past Medical History

  • Carers

    Do you need/have anyone who looks after you or your daily needs as Carer? (optional)
    Do you care for anyone else? (optional)
  • Communication Needs

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