New Patient Questionnaire V2

This questionnaire provides us with some background on your current health. Please make sure you fill in all questions.

Last Updated: 07/10/2020

Your Contact Details









Information About You






Occupation

Those who work will most likely spend the majority of their time in this environment therefore its important to know what you do. Your job description can give clinicians an idea of how psychically, mentally, and emotionally challenging your job is. If you are a carer please ask reception for a Carers Pack.









Smoking status

There are many ways to quit smoking, why not make an appointment with our HCA who can offer advice and support to help you quit?







Alchohol

Do not forget that alcohol contains calories. Regularly drinking more than recommended can have a noticeable impact on your waistline. Try to keep to the recommended daily alcohol limits to reduce the risk of serious problems with your health, including risks to your heart health.











Medical History

A family medical history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and diabetes. These complex disorders are influenced by a combination of genetic factors, environmental conditions, and lifestyle choices.





Next of Kin


Contacting You


Registration Checklist

All online forms need to be completed, the surgery may reject your registration if any sections are incomplete.