New Patient Questionnaire

Newnham Walk Surgery New patient Questionnaire (Adult)

Last Updated: 17/09/2020

Your Contact Details

Title

Name *

Previous Surname

Date of Birth *

Address *

Postcode *

College Address (students only) *

Length of stay in Cambridge *

Town and Country of Birth *

Occupation *

Home Number

Mobile Number *

Email Address *

Information About You

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

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Women

Will

Do you hold a Living Will? *

Yes No

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? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

HOW OFTEN DO YOU HAVE A DRINK CONTAINING ALCOHOL? *

HOW MANY UNITS OF ALCOHOL DO YOU DRINK ON A TYPICAL DAY WHEN YOU ARE DRINKING? *

HOW OFTEN HAVE YOU HAD 6 OR MORE UNITS IF FEMALE OR 8 UNITS OR MORE IF MALE ON A SINGLE OCCASSION IN THE LAST YEAR ? *

IN THE LAST YEAR HAS A RELATIVE OR FRIEND OR DOCTOR OR OTHER HEALTH WORKER BEEN CONCERNED ABOUT YOUR DRINKING? *

Yes No

HOW OFTEN IN THE LAST YEAR HAVE YOU FAILED TO DO WHAT WAS NORMALLY EXPECTED OF YOU BECAUSE OF DRINKING? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

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

Emergency Contact, please give name and telephone number *

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Register for Online Services

It is strongly receommended that you register for Online Services. Which Online Service would you like to acces to? (Tick all that apply)

Signature

Signature *

Date *

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