New Patient Health Questionnaire

 

Thank you for completing our Practice Health Questionnaire.

If you’re here, it means you should already have filled in the Registration Form. The registration form is an official requirement of NHS Scotland, and must be completed and signed before you can register with any medical practice in Scotland.

Our Health Questionnaire is a form that helps give our clinical staff an idea of your past medical history and your current health status. You can either fill in and submit the online form below, or you can print off the PDF or Word versions from here to complete and bring into the practice by hand.

Please note: our doctors and nurses will need the questionnaire to be filled in and back with the practice before they can see you for your first appointment.

    -- PERSONAL DETAILS --

    Your Title: Your Full Name:
    Your Date of Birth: Your Gender: MaleFemale
    Home phone number: Permission to leave voicemail message? YesNo
    Mobile phone number: Permission to leave voicemail message? YesNo
    Tick here if you consent to allow the Practice to text you non-clinical information and reminders to your mobile number: Consent given
    Your Email Address:
    Next of kin (incl name, address, tel no and your relationship):
    Date arrived in UK (if arrived from overseas): Date your course is expected to finish:
     

    -- SMOKING HABIT --

    Do you currently smoke: YesNo If "Yes", how many cigarettes per day:
    If you are a current smoker, would you like any help from the practice to quit? YesNo
     

    -- ALCOHOL INTAKE --

    Do you drink alcohol: YesNo If "Yes", how many units per week:
    1 unit = 1 small glass of wine, 1 single measure of spirit, or 1 half pint of (standard strength) beer
    Click here to access an alcohol unit calculator
     

    -- MEDICATION --

    Are you on any regular medication (incl the contraceptive pill): YesNo
    If "Yes", please state name and dose:
    Are you allergic to any medicines: YesNo
    If "Yes", please give details of medicine and severity/type of reaction:
     

    -- WOMEN ONLY --

    What was the date of your last smear? What was the result?
    Where was your last smear taken?
    No of pregnancies? No of children
     

    -- MEDICAL HISTORY --

    Do you have/have you had any of the following conditions?
    EPILEPSY YesNo If "Yes", approx date of diagnosis:
    DIABETES YesNo If "Yes", approx date of diagnosis:
    ASTHMA YesNo If "Yes", approx date of diagnosis:
    If Asthmatic, have you used your inhalers in the last 12 months? YesNo
    Please give details of any other illness, accidents, hospital admissions, investigations or operations you've had:
    1)
    2)
    3)
    4)
     

    -- FAMILY HISTORY --

    Had a first degree relative (parent or sibling) suffered from any of the following conditions?
    CANCER YesNo Who? At what age?
    STROKE YesNo Who? At what age?
    HEART DISEASE YesNo Who? At what age?
    DIABETES YesNo Who? At what age?
    Do any other illnesses run in your family? YesNo
    If "Yes", please give details:
     
    Please give details of the current state of your family's health
    Relative Age State of health Age at death Cause of death
    FATHER
    MOTHER
    SIBLING 1
    SIBLING 2
    SIBLING 3
    OTHER SIBLINGS
     

    -- INTERPRETER NEEDS--

    What is your main language?
    Do you need an interpreter or sign language support? YesNo
     

    -- ETHNICITY --

    What is your ethnic origin?
    Choose ONE section from A to G then tick ONE box which best described your ethnic group or background
    A. WHITE
    B. MIXED or MULTIPLE ETHNIC GROUPS
    C. ASIAN, ASIAN SCOTTISH or ASIAN BRITISH
    D. AFRICAN
    E. CARIBBEAN or BLACK
    F. OTHER ETHNIC GROUP
    G. NO ANSWER


    Please note: While we do everything possible within the practice to ensure your information is secure, this website is outwith the NHS Lothian network and no transmission over the Internet can be guaranteed to be 100% secure. Therefore, you provide us with your information at your own risk.