Health Questionnaire

This form is used to accompany the Practice Registration Form. Please fill it to the best of your ability. Information put on this form will be stored in your medical record

 

Fields marked * are required

Last Updated: 26/08/2022

  • Patient Details

    Sex

  • Health Information

  • Smoking

    Are you currently a smoker?
    If 'No', have you ever smoked? (optional)
    Would you like advice on giving up smoking? (optional)

  • Alcohol

  • Blood Pressure

    As part of our new patient health screening program we require a blood pressure recording for all new patients. You can measure the reading at home if you have a blood pressure machine or at a local pharmacy.

    Alternatively, if you have your latest blood pressure readings, please enter them here.

    Date of reading (optional)
    For example, 15 3 1984

  • Medical History

    Please note: If you have medications please ensure you book a routine appointment so your repeat prescription(s) can be set up BEFORE they are due - there is a lead time to routine appointments being available.

    Do you suffer with any of the following medical conditions?
    Have you ever suffered from? (tick as appropriate) (optional)
    Do you have any other mental health issues? (optional)
    Have you ever refused treatment/screening of any kind?
    Do you have any allergies?
    Have you ever had an allergic reaction? (optional)
    Do you have any disability, impairment or sensory loss ?
    Are you under any medication/injections currently?
    Are you also under medication prescribed by hospital, outside the GP?

  • Family History

    Have your parents, brothers or sisters suffered from any of the following medical conditions?

  • Additional Questions

    Are you... (optional)

  • Preferred Chemist

  • Cervical Cytology

    Have you previously had a Cervical Smear/Pap Test?
    If yes, what was the date of your last smear test? (optional)
    For example, 15 3 1984
    What was the result of your last smear test? (optional)

  • Pregnancy

    Are you currently pregnant? (optional)

  • Will

    Do you hold a living will?

  • FOR PATIENTS AGED 65 AND OVER OR THOSE WITH A CHRONIC DISEASE (E.G. ASTHMA OR DIABETES)

    Have you ever had a flu vaccination or a pneumococcal vaccination? (optional)

  • Privacy and Security

    Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

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