Wargrave surgery

WARGRAVE SURGERY
NEW PATIENT QUESTIONNAIRE
Patient Details – PLEASE PRINT DETAILS
(Please circle the details that best describe you)
First Name:
Middle Name(s):
Surname:
Date of Birth:
Gender:

Title:
Mr/Mrs/Miss/Ms/Other(Please specify)

Marital Status:
Married/Single/Widowed/Divorced/
Separated/Co-habiting
Address:
First Line
Street
Town
County
Postcode
Responsible Local Authority: Wokingham / Henley/ Maidenhead/Other
Can be identified from council tax forms or colour of your homes rubbish bins.

Telephone Numbers:
Home ………………………………………………………………………….
Mobile ………………………………………………………………………….
Work …………………………………………………………………………….
We will use your mobile phone number to send text messages to remind you
about booked appointments. Appointment reminders YES / NO

Email address:
Occupation (or name of educational establishment if student/pupil)

Global (G) drive/PROTOCOLS/New Patient Questionnaire
Next of Kin Details
Name:
Relationship:
Address:
First line
Street
Town
County
Postcode
Telephone Numbers:
Home …………………………………………………………
Mobile …………………………………………………………
Work …………………………………………………………
Ethnicity ,First Language and Disability (The NHS is required to collect this
data)
Ethnic Origin (PleaseCircle which best describes your ethnic or racial origin)
White British
Other racial group (please specify)
First language (please indicate your First language):
Please describe your proficiency in English language. Fluent/Some help
required
Do you have a disability?
Mobility Problem (e.g. Stick / Wheelchair / Other)
Sense organ ( e.g. Sight / Hearing etc
Communication
Do you have any Communication problems?
Access to transport : Own Car / Public Transport / Other ( please specify)

Global (G) drive/PROTOCOLS/New Patient Questionnaire
Medical Problems
Do you have any current active medical conditions (please list)
( medical problems for which you receive GP or hospital treatment or for
which you need to take medication)
1
2
3
4
5
6
Do you have any significant past history
1
2
3
4
5
6
Current Medication:
Name
Formulation Dosage Instructions for use
Example: Ramipril

Details of Allergies:
Name of Allergen
What happened
Occurred
Treatment

Immunisations
Please give date of last tetanus and any other immunisations you can
remember:

Immunisations
Any problems
Global (G) drive/PROTOCOLS/New Patient Questionnaire

Personal Wellbeing
Vegetarian
Other (Pls specify)
Exercise:
Inactive
Moderate Vigorous

Family History
Does anyone in your family (parents/brothers/sisters) have any of the
following (please circle) and identify the family member
Family member
Inherited Condition
affected

Condition:
Family Member affected

Smoking Status (please circle which best describes you)
Do you currently
Global (G) drive/PROTOCOLS/New Patient Questionnaire Amounts used

Alcohol (please circle which best describes you)
How often do you have a
contains
alcohol?
standard
alcoholic drinks do you
have on a typical day
when you are drinking?
How often do you have 6
or more standard drinks
on one occasion?

Carers
Are you a carer for another person who is ill or infirm?
(Please give details)
Name of the person for who you care;
Relationship to You;
Nature of their care needs ;
Impact on you of being a carer:
Would you like details of the Carer Organisations in the Wargrave area?
Yes/ No

Women Only
Details of any pregnancies:
Current method of contraception (if applicable):
Date of last Smear:


Signed: …………………………………
Dated: ………………….
The details you have given on this form will be incorporated in your computer record, which will only be available to people involved in your medical care, unless you give permission for details to be shared with a third party. Global (G) drive/PROTOCOLS/New Patient Questionnaire

Source: http://www.thewargravesurgery.co.uk/website/K81055/files/New_patient_questionnaire.pdf