New Patient Health Questionnaire (Adult) – Beacon Health Mossley Hill

Your contact details

Title(Required)

Mrs

Miss

Other

Please add your title

Name(Required)

First Last

Date of birth(Required)

Day

Month

Year

Sex(Required)

Male

Female

NHS number (if known)

Get help to find your NHS number online

Home address(Required)

Post code(Required)

Home phone number

Mobile phone number

Email address(Required)

Enter Email Confirm Email

Occupation

Next of kin name(Required)

First Last

Relationship to you:(Required)

Contact number:(Required)

Information about you

Ethnicity(Required)

White (UK)

White (Irish)

White (Other)

Black Carribbean

Black African

Black Other

Bangladeshi

Indian

Pakistani

Chinese

Other

Religion(Required)

C of E

Catholic

Other Christian

Buddhist

Hindu

Muslim

Sikh

Jewish

Jehovah's Witness

No religion

Other

Communication needs

What is your first language?(Required)

Do you need an interpreter?

Yes

Language of interpreter

Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record.

Hearing aid

Lip reading

British sign language

Large print

Makaton sign language

Braille

Guide dog

Do you have a learning disability?(Required)

Yes

Carers

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Are you a carer?(Required)

Yes - Informal/Unpaid carer

Yes - Occupational/Paid Carer

Name of the person you care for:

First Last

What is your relationship with the person you care for?

DOB of the person you care for:

Day

Month

Year

Address of the person you care for:

Telephone number of the person you care for:

NHS number of the person you care for:

Please contact the following number for advice on a free carers Health and Wellbeing check 03456 434 435

Are you being cared for?(Required)

Yes

Name of your carer:

First Last

What is your relationship with your carer?

DOB of your carer:

Day

Month

Year

Address of your carer:

Telephone number of your carer:

NHS number of your carer:

If you consent to your Carer being informed of any medical information about you which is held at the practice, please check the box below; if NOT leave blank

I am happy for my carer to be informed of any medical information about me which is held by the practice.

Medical information

Have you suffered from any of the following conditions?

Asthma

COPD

Epilepsy

Heart disease

Heart failure

Hypertension (High blood pressure)

Diabetes

Kidney disease

Stroke or Transient Ischaemic attacks

Depression or mental health problems

Underactive thyroid

Cancer

Please state the type of cancer

Please let us know which mental health problem you suffer from or have received treatment for in the past

Depression

OCD

Anxiety

Bipolar disorder

Please state the year when you were first diagnosed (or approximate date)

Do you have any other mental health problems? If yes, please state these below

Any other conditions, operations or hospital admission details:

ALLERGIES: Please list any allergies or sensitivities you have including drug allergies below

Please list any immunisations or vaccinations you have had

Current medication

Please check and include as much information about your current medication below Please give us your previous repeat medication list if possible and a medication review appointment may be needed

Family history

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Asthma

COPD

Epilepsy

Heart disease

Stroke

Blood pressure

Diabetes

Kidney disease

Liver disease

Depression

Thyroid

Cancer

Other

Please give any details if you have ticked any of the above

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? If yes, please give the date below.

Have you had a pneumococcal vaccination? If yes, please give the date.

Women only

Do you use any contraception?

If needed, please book an appointment

Yes

Do you have a coil or implant in situ?

Yes

Date inserted

Are you currently pregnant or think you may be?

Yes

Expected due date

Have you ever had a cervical smear?

Yes

Please let us know when, where and what your result was

Your lifestyle

What is your height?

What is your weight?

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2 to 4 times / month

2 to 3 times / week

4+ times / week

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

None

1 - 2

3 - 4

5 - 6

7 - 9

10+

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?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption – Part Two

Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

Have you or somebody else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Yes, during the last year

Score - part 2
0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

Smoking

What is your smoking status?(Required)
Never smoked
Ex-smoker
Smoker

Do you use an e-Cigarette?(Required)
No
Ex-user
Yes

How many cigarettes did/do you smoke per day?

Would you like advice/help on quitting?
For further information please see: www.nhs.uk/smokefree
Yes
No

Living will

Do you hold a living will?
(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
Yes
No

Electronic prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use
Please give the name and address of the pharmacy

Patient participation group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group?
Yes
No

Consent

Can we contact you by text message?(Required)
Yes
No

Can we contact you by email?(Required)
Yes
No

Not for urgent medical help(Required)
Yes, I understand this form is NOT for urgent medical help

Consent(Required)
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.

Comments
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