Medical Questionnaire for New Patients

Questionnaire for new patients to complete

Last Updated: 21/03/2022

Patient Details

Childhood Immunisations (Under 5's)

Please state which (if any) you have had and give approximate dates.

Medical History

Please say if you have had any of the following and an approximate age

Chickenpox

German Measles

Measles, Mumps, Rubella

Whooping Cough / Pertussis

Scarlet Fever

Rheumatic Fever

Tuberculosis

Allergies

Do you have any allergies to any drugs? *

Yes No

If 'Yes' please state the drug allergies you have.

Do you have any non-drug allergies? *

Yes No

If 'Yes' please state the non-drug allergies you have.

Health Promotion

Do you smoke? *

If 'Yes' how many cigarettes or ounces of tobacco do you smoke a week? *

If 'Ex - smoker' When did you quit smoking? *

How often did you have a drink containing alcohol in the past year? *

How many drinks did you have on a typical day when you were drinking in the past year? *

How often did you have six or more drinks on one occasion in the past year? *

Exercise

What exercise do you do and how regularly?

Medication

Are you taking any medication? *

Yes No

If 'Yes' What medication are you taking and what is it for? *

Chronic Disease

Operations and Hospital Admissions

Please list any operations and reasons for hospital admissions with dates (if Known)

Accessible Standard

The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss can receive, access and understand information, for example in large print, braille, or via email, and professional communication support if they need it, for example from a British Sign Language Interpreter. Individuals most likely to be affected by the Standard include people who are blind or partially sighted also people who are deaf, partially deaf, deaf/blind and people with a learning disability.

Declaration

Please provide a signature *

Date of Birth *

Date of Signature *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Sellindge Surgery website

Medical Questionnaire for New Patients

Further Information