Online New Patient Questionnaire (Adult) Patient DetailsTitlePlease Select…MrMrsMissMsMxDrSex Male Female Other Name First Name Surname Date of Birth Day Month Year Occupation Optional Contact NumberEmail Address Current Address Street Address Address Line 2 City Post Code Ethnic OriginPlease Select…EnglishWelshScottishNorthern IrishBritishIrishGypsy or IrishTravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed / Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black / African / Caribbean backgroundArabPrefer not to sayOther (Please Specify)Communication ConsentDo you consent to us contacting you by text and/or email? Yes by text and email Yes by email only Yes by text only No Any email address and/or mobile number given for a person over the age of 14 years must be the person’s own details and not those of their parent/guardian. Under the Data Protection Act we have to inform you that the contents of any e-mails will not be confidential and secure. Any information we obtain from you will be used only for us to communicate with you. This information will not be passed on to any third party and will not be kept for longer than necessary. Confidentiality and security cannot be guaranteed whilst in transit and all e-mails should contain the minimum of identifiable information. Any e-mails you send will be stored on your e-mail provider’s server and should be deleted as soon as possible as the NHS have no control over these mail servers. PLEASE NOTE: YOU CAN VIEW OUR PRIVACY NOTICE ON OUR WEBSITE: www.wyreforesthealthpartnership.co.ukNext of Kin / Emergency ContactName First Name Surname Contact NumberRelationship CarersAre you a carer? Yes No If 'yes' for whomAre you being cared for? Yes No If 'yes', by whom?If you are a carer, have you completed a yellow carer card to help us identify your needs? Yes No Summary Care RecordHave you received information on the Summary Care Record? Yes No (SCR is where your basic medical history is shared with hospitals across England in case of an Emergency)Do you wish to opt out? Yes No (i.e. not let any information about you be available to hospitals, A&E or Out of Hours, if needed)Smoker StatusDo you Smoke? Yes: Current Smoker No: Ex-Smoker No: Never Smoked What do you smoke and how much do you smoke in a week? When did you stop smoking? Day Month Year Alcohol IntakeDo you drink alcohol? Yes No This is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) If 'yes', how many Units a week? 1-2 3-4 5-6 7-9 10+ How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Information About YouDo you exercise? Yes No If 'Yes', please provide detailsWhat is your height? What is your weight? Have you got a recent Blood Pressure Reading? Yes No If 'yes', please provide details Have you had any serious illness or operation in the past?Please provide details or enter “No History”Do you take any regular medications? Yes No If 'yes', please provide detailsNote: If you have nominated a specific pharmacy for your prescriptions you may need to change this to a more local pharmacy.Do you have any allergies to any drugs, food or other substances? Yes No If 'yes', please provide detailsDo you need to carry an adrenaline pen? Yes No Have you, your parents, siblings suffered with any of the following? Asthma/COPD Heart Attack/Heart Disease Mini Stroke/Stroke/TIA Epilepsy High Blood Pressure Diabetes Glaucoma Cancer Kidney Disease Depression/MentalHealth problems Learning Difficulties Thyroid problems Osteoporosis Atrial Fibrillation Dementia Other (please Specify) No If you checked any of the above, please provide details(Please specify what condition, which family member and when they were diagnosed)If 'Other', please specify(Please specify what condition, which family member and when they were diagnosed)Vaccination History Pneumonia Polio Tetanus Flu German Measles Shingles Any Other (Please tick the vaccines you’ve received)Please Specify dates of most recentHave you made an Advance Directive/Living Will? Yes No (If ‘yes’ please provide a copy to the practice)Are you currently under hospital care? Yes No Hospital Name Nature of problem consultant (if known) (if unknown, state “Unknown”)WomenHave you ever had a cervical smear? Yes No When was your last cervical smear? Day Month Year What was the result? Have you signed a Smear Disclaimer Form? Yes No Date signed Day Month Year Are you in need of contraception? Yes No Are you on HRT? Yes No Do you have a ring pessary? Yes No Do you have a Coil or Implant? Yes No When was it fitted? Day Month Year Special RequirementsDetail below any specific needs you have so the Practice can ensure they are identified and accommodated by taking the appropriate actionDo you have any sensory impairments? (i.e. Speech, Hearing, Sight) Yes No Please provide detailsAre you an ‘Assistance Dog’ User? Yes No Do you have any religious or cultural needs? Yes No Please SpecifyDo you require the help of a Translator / Interpreter? Yes No What is your main spoken language? In ClosingPatients should provide proof of identification and proof of address when registering. You will need bring 1 PHOTOGRAPH ID AND 1 UTILITY BILL SHOWING CURRENT ADDRESS to complete the registration process. This information will only be used by doctors and staff of the Medical Centre and will be treated with confidentiality.Signature (Patient’s Full NameComments OptionalThis field is for validation purposes and should be left unchanged.