Medical Questionnaire for New Patients

Medical Questionnaire for New Patients

Questionnaire for new patients to complete

  • Patient Details

    Sex
    Date of Birth
    For example, 15 3 1984
    Marital Status (optional)
    Do you have an email address you wish to be contacted on? (optional)

  • Childhood Immunisations (Under 5's)

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

    Eight Weeks Immunisations (optional)
    Twelve Weeks Immunisations (optional)
    Sixteen Weeks Immunisations (optional)
    One Year Old's Immunisations (optional)
    Three Years Old Immunisations (optional)

  • Medical History

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

  • Allergies

    Do you have any allergies to any drugs?
    Do you have any non-drug allergies?

  • Health Promotion

  • Exercise

  • Medication

    Are you taking any medication?

  • Chronic Disease

    Do you or any of your family members suffer from Asthma? (optional)
    Do you or any of your family members suffer from Diabetes? (optional)
    Do you or any of your family members suffer from Epilepsy? (optional)
    Do you or any of your family members suffer from High Blood Pressure? (optional)
    Do you or any of your family members suffer from Heart Disease? (optional)
    Have you or any of your family members had a stroke? (optional)
    Do you or any of your family members suffer from Cancer? (optional)
    Does you or any of your family members suffer from Depression? (optional)
    Are there any other diseases not listed above? (optional)

  • Operations and Hospital Admissions

  • 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.

    Do you have communication Needs?
    Do you need a format other than standard print?
    Do you have any special communication requirements?
    Do You have a carer?
    If you have a carer do they need communication assistance?
    Do you consent to the practice contacting your main carer regarding your care?

  • Declaration

    Date of Birth
    For example, 15 3 1984
    Date of Signature
    For example, 15 3 1984
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Page last reviewed: 21 March 2022
Page created: 23 July 2020