In an emergency call 999. Out-of-hours call 111. Askern Medical Practice: 01709 514443

Askern Medical Practice

New patient health questionnaire (adults)

Complete this form and our team will process your request. We aim to respond within 2 working days.

This form is not for urgent problems. If you need help today, phone the practice on 01709 514443. In an emergency call 999.

NHS Number (optional)

If you do not have a NHS number what is the date you came to the UK? (optional)

Name

First name

Last name

Name

First name

Last name

Previous Surname (if applicable) (optional)

Gender

Date of Birth

Home Telephone (optional)

Mobile Number

Do you content to be contacted via SMS?

AddressStreet address

Town or city

Postcode

Previous Address (optional)Street address

Town or city

Postcode

Do you consent to be contacted Via email?

Occupation (optional)

Do you have a next of kin?(emergency contact person)

Name

First name

Last name

Phone

Relationship to you

GP Name

AddressStreet address

Town or city

Postcode

Country of Birth

Ethnicity

Religon (optional)

What is your main spoken language?

Do you need an interpretor?

Do you have any communication needs?

Do you have a learning disability?

Do you have a Carer?

Are you a Carer?

Have you suffered from any of the following conditions?

Any other conditions, operations or hospital admission details: (optional)

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here: (optional)

Relative (optional)i.e Parent, Sibling, Grandparent, Aunt/Uncle/Cousin etc

Medical Problem (optional)

Please record any allergies or sensitivities

Please give us your previous repeat medication list if possible, a medication review appointment may be needed: (optional)

How many times a week do you exercise for more than 30 minutes?

How often do you have a drink containing Alcohol?

Units

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Total Score:

4 or less

5 or more

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Total Score?

Do you smoke?

How many cigarettes did/do you smoke a day?

Would you like help to quit smoking?For further information, please see: www.nhs.uk/smokefree

Height

Weight

Are you Female?

Do you use any contraception?

Are you currently pregnant or think you may be?

Expected due date

Are you a student?

I am less than 24 years old and have had two doses of the MMR Vaccination

I am less than 25 years old and have had a Meningitis C Vaccination

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: (optional)

Would you like to be involved in our Patient Participation Group?

Blood Donation

I am already a blood donor

I wish to be a blood donor

I do not wish to be a blood donor

Organ Donation

I am already registered as a donor

I wish to be a donor – all body part

I wish to be a donor – for these body parts:

I do not wish to be a donor

Which organs would you like to donate: (optional)

Name

Date

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

I wish to give EXPRESS CONSENT for medication, allergies and adverse reactions only to be included in my Summary Care Record

I wish to give EXPRESS CONSENT for medication, allergies, adverse reaction and additional information to be included in the my Summary Care Record

I DO NOT CONSENT to have my Summary Care Record and do not wish to have one

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

Yes (recommended option)

Do you consent to having an Enhanced Summary Care Record with Additional Information? (optional)

Yes (recommended option)

Date (optional)