New Patient Questionnaire – Adult Name First Last Date of Birth Day Month Year Gender Male Female Other Please specify Phone NumberEmail Address Enter Email Confirm Email Smoking StatusWhat is your current smoking status? Never smoked Ex-smoker Current smoker How many do smoke a day? How many years smoked? Date stopped smoking Alcohol StatusAlcholo Units: 2 units = 1 pint beer or 1 glass of wine (175mls), 1 unit = single measure of spirits, 1.5 units = alcopop or a can of Lager, 9 units = 1 bottle of wine.How much alcohol do you consume in a week? How often do you have a drink containing alcohol?NeverMonthly or less2-4 per month2-3 per week4+ per weekHow many alcoholic drinks do you have on a typical day when you are drinking?1 – 23 – 45 – 67 – 810+How often do you have 6 or more standard drinks on one occasion?NeverLess than MonthlyMonthlyWeeklyDailyCarer InformationA carer is someone who provides unpaid support to someone who could not manage without their help due to a physical or mental health condition, physical or learning disability, frailty or substance misuse problems.Are you a carer? Yes No Please SpecifyNext of KinName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title Optional First Optional Last Optional Relationship Optional Contact Number OptionalFor Women OnlyWhen was your last smear? Optional Where did you have your smear? Optional Was it normal? Yes Optional No Optional Any serious illnesses, operations or admissions?Are you allergic to anything?Ethnicity Group (Please tick the appropriate box)What is your Ethnicity Group?White – BritishWhite – IrishWhite – OtherBlack – BritishBlack – AfricanBlack – CaribbeanBlack – OtherAsian – BritishAsian – IndianAsian – PakistaniAsian – BangladeshiAsian – OtherMixed – White & Black Caribbean Mixed – White & Black AfricanMixed – White & AsianMixed – OtherChineseOtherPrefer Not To SayFirst Spoken Language Interpreter? Yes No Summary Care RecordWould you like to have a summary care record? (shared record with healthcare staff) Yes No Please complete our opt-out form separately once you have completed this form. Patient Online AccessAccessing GP services at home, work or on the move 24 hours a day. Includes appointment booking, requesting repeat medication, secure messaging and viewing of medical records. Please speak to a receptionist to register.Accessible Information StandardFor patients with a disability, impairment or sensory loss.My information and communication preferences are: Easy Read Optional Large Print Optional BSL Optional Email Optional Text Optional Other Optional Please specify
