NEW PATIENT HEALTH QUESTIONNAIRE PLEASE COMPLETE ALL PAGES Information about you

Transcription

1 PLEASE COMPLETE ALL PAGES Infmation about you Title Previous Surname(s) Calling Name: Telephone Number: What is your height? Surname First names Date of Birth What is your first language? Mobile Number: What is your weight? Would you like to book appointments online? Would you like to der your prescriptions online? Do you need assistance accessing our services? If yes Do you require a language translat including BSL If yes - Do you have an assistance dog e.g. guide dog, hearing dog etc If yes Do you use a walking aid mobility scooter? If you have a disability, impairment sensy loss: Do you need infmation in a different fmat to a standard letter? If Yes - Please complete an Accessible Infmation Fm Do you need any communication suppt? If Yes - Please complete an Accessible Infmation Fm Ethnic Group White British Irish Other If other please specify Black Caribbean African Other If other please specify Asian Indian Pakistani Chinese Other If other please specify Mixed White + Black Caribbean White + Black African White + Asian Other Other If other please specify Page 1 of 5 Health Questionnaire f new patients v

2 Smoking Do you smoke? If '', have you ever smoked? How many per day? If you do currently smoke, how many cigarettes ounces of tobacco do you smoke per day? Would you like advice on giving up smoking? Carer Do you have a Carer? Yes* Are you a Carer? Yes* * If you have answered Yes to any of the above questions, please ask f a Carer s Pack. The Carer s pack contains further infmation f you about suppt available to you and an additional infmation fm that we ask you to complete. Military Serving / Veteran Dependant Are you currently serving in the British Armed Fces? Are you a Military Veteran of the British Armed Fces? If you are / have served in British Armed Fces, please indicate which service. (F Reservists please also indicate which service) Royal Navy / Royal Marine British Army Royal Air Fce Reservist Have you deployed on operations e.g. OP TELIC / HERRICK etc? (F Reservists/Territial Army please confirm if you have served as Regular service personnel f me one day) Are you a: Dependant of a current serving member of the British Armed Fces? Dependant of a fmer serving member of the British Armed Fces? Next of Kin Please give name, address and telephone number of next of kin Relationship to you: Emergency Contact: If Yes - Please provide their telephone / mobile number: Permission to disclose Medical Infmation Please sign and date below: Page 2 of 5 Health Questionnaire f new patients v

3 Signed Date. Page 3 of 5 Health Questionnaire f new patients v

4 Alcohol Questions How often have you had 6 me units if female, 8 me if male, on a single occasion in the last? How often during the last have you been unable to remember what happened the night befe? Has a relative friend, doct other health wker been concerned about your drinking suggested that you cut down? How often during the last have you failed to do what was nmally expected from you because of your drinking? Scing: Scing system Yes, but not in the last Yes, during the last Your sce A total of 3+ may indicate hazardous harmful drinking TOTAL If you sce 3 me, please fill in the me detailed questionnaire at the end of this questionnaire Page 4 of 5 Health Questionnaire f new patients v

5 Alcohol Users Disders Identification Test (AUDIT) Questions How often do you have a drink that contains alcohol How many standard alcoholic drinks do you have on a typical day when you are drinking? How often do you have 6 me standard drinks on one occasion? How often in the last have you found you were not able to stop drinking once you had started? How often in the last have you failed to do what was expected because of drinking? How often in the last have you needed an alcoholic drink in the mning to get you going? How often in the last have you had a feeling of guilt regret after drinking? How often in the last have you not been able to remember what happened when drinking the night befe? Have you someone else been injured as a result of your drinking? Has a relative / friend / doct / health wker been concerned about your drinking advised you to cut down? Scing system times 4 + times times less per per week per week month Yes, but not in the last Yes, but not in the last Yes during the last Yes, during the last Your Sce Scing: 0-7 = Sensible Drinking, 8-15 = hazardous drinking, harmful drinking and 20+ = possible dependence Page 5 of 5 Health Questionnaire f new patients v