New Patient Questionnaire Form - Ilford Lane Surgery

Title *

First Name *

Last Name *

Middle Name(s)

Date of Birth *

Sex *

Male

Female

Other

Address *

Postcode *

Phone Number *

Other Number

NHS Number

Health Information

Are you currently a smoker? *

Yes No

If 'No', have you ever smoked?

Yes No

If yes, how many per day?

What type of smoking are you engaged in? (example cigarettes, cigars, etc.)

Would you like advice on giving up smoking?

Yes No

How often do you have a drink containing alcohol? *

If you do drink, how many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have 6 or more drinks on one occasion?

How many drinks containing alcohol do you consume weekly?

In 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? *

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.

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.

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

Asthma

Epilepsy

Hypertension

Diabetes

Heart Disease

Stroke

Cancer

None

Other

Additional Questions

Preferred Chemist

Cervical Cytology

Have you previously had a Cervical Smear/Pap Test? *

Yes No

If yes, what was the date of your last smear test?

What was the result of your last smear test?

Negative

Positive

Are you currently pregnant?

Yes No

If yes, how many children do you have (If any)?

What form of contraception are you using (If any)?

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?

Yes, both

Yes, flu vaccination

Yes, pneumococcal vaccination

Never

If yes, please enter the date of the vaccination(s)

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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Health Questionnaire

Further Information