New patient health questionnaire

Please complete this form once you have successfully registered to join the surgery. This is a questionnaire for our newly-registered patients so we can quickly update your records whilst we wait for your previous surgery to transfer your medical records to us.

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Your details

Name *

First

Middle

Last

Date of birth *

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Sex *

• Male
• Female

Phone number *

Email address

Additional information

Do you currently work? *

• Yes
• No

What is your current occupation? *

Do you have any disabilities or communication needs? *

• Yes
• No

What disabilities and/or communication needs do you have? *

Do any of the following statuses apply to you?

• Military veteran
• Asylum seeker
• Refugee
• Homeless

Alcohol use

How often do you have a drink that contains alcohol? *Select choice…NeverMonthly or less2-4 times a month2-3 times a week4+ times a week

How many standard alcohol drinks do you have in a typical day when you are drinking? *Select choice…1-23-45-67-810 or more

How often do you have 6 or more standard drinks on one occasion? *Select choice…NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Family history

Do any of your family members suffer with any of the following?

• Heart disease
• Stroke
• Diabetes
• DVT

Who suffers with heart disease? *Select choice…MotherFatherBrotherSister

You can select more than one option from this list.

Who suffers with a stroke? *Select choice…MotherFatherBrotherSister

You can select more than one option from this list.

Who suffers with diabetes? *Select choice…MotherFatherBrotherSister

You can select more than one option from this list.

Who suffers with DVT? *Select choice…MotherFatherBrotherSister

You can select more than one option from this list.

Medical history

Have you had any operations? *

• Yes
• No

Please list your previous operations *

Do you have any medical conditions? *

• Yes
• No

Please list your medical conditions *

Do you have any allergies or addictions? *

• Yes
• No

Please list your allergies and/or addictions *

Do you take medication? *

• Yes
• No

Please list your medications *

Women's health

Have you ever had a cervical smear test? *

• Yes
• No

Date of last smear *

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Last smear result *Select choice…HPV negativeHPV positive, no abnormal cellsHPV positive and abnormal cells

Have you had a hysterectomy? *

• Yes
• No

statuses Email you

Date of hysterectomy *

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Are you currently on contraception? *

• Yes
• No

What method of contraception are you using? *

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