New Patient Questionnaire

Version 5

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Previous GP

Name and Address of Previous GP *

Proof of Identity and Address Provided

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Information About You

Medical Information

Are you taking any medication? Please list medications and doses:

What is your height? *

What do you weigh? *

If you know a recent blood pressure, please enter it here:

Are you allergic to any medicines? *

Yes No

If your previous GP was outwith NHS Highland, it can sometimes take several months for your notes to reach us. Do you have any significant medical history you would like to advise us of?

Are you registered disabled? *

Yes No

If yes, please give details

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked?

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Activity

In terms of how active you are, would you consider yourself: *

Very active : at least 150 minutes of moderate activity, or 75 minutes of vigorous activity every week

Fairly active : regular moderate or gentle activity

Fairly inactive : occasional moderate or gentle activity

Sedentary : unable to exercise

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of your drinking? *

How often during the last year have you been unable to remember what happened the night before because you had been drinking *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Advance planning and legal documentation:

Do you hold a Living Will or Advance Directive? If so it would be useful for the practice to have a copy of this.

Yes No

Have you granted a Power of Attorney? If so it would be useful for the practice to have a copy of this.

Yes No

If you have granted a Do Not Resuscitate order, it would be useful for the practice to have a copy of this

Yes No

Family History

Is there a close family history of any of the following? *

Ischaemic Heart disease / angina / heart attack (before the age of 60)

Ischaemic Heart disease / angina / heart attack (after the age of 60)

Stroke disease

Diabetes

Asthma

High Blood Pressure

Cancer

If so, or if there are other familial conditions, please can you give details below:

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Contacting You

Do you give permission for the practice to contact you via text message and email regarding appointments, results and reminders? *

Yes No

We are a Dispensing Practice. Which surgery would you prefer to collect your routine prescriptions from? *

Munlochy

North Kessock

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

Yes No

Signature

Signature *

Date *

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New Patient Questionnaire

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