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Secure Surgery Website
From Wiggly-Amps Ltd
01263 834 648    info@wiggly-amps.com

New Patient Questionnaire

Forename. *

Surname. *

Date of Birth. *

 Format: dd/mm/yyyy

Home Address.

E-mail address.

Home Phone Number.

Mobile Phone Number.

Do we have your consent to contact you on these numbers and if necessary leave a message or send a text message?.

Marital Status.

Is this the first time you have applied to go on an NHS GP list?.

Have you ever been a patient at this surgery?.

Town and Country of Birth:.

If not UK, what date did you arrive?.

 Format: dd/mm/yyyy

How long do you plan to be in the United Kingdom?.

What is your ethnic category?.

What is your first language?.

Do you speak any English?.

Do you need an interpreter?.

Do you use British sign language?.

What is your occupation?.

Next of Kin Name.

Address/Tel. No..

Weight.

Height.

Any special diet?.

Waist circumference.

How much regular exercise do you do?.

Smoking status.

How often do you have a drink containing alcohol?.

How many standard drinks containing alcohol do you have on a typical day when you have a drink?.

How often do you have 6 or more standard drinks on one occasion?.

How many units of alcohol do you drink in a week?.

Have you ever had your blood pressure tested?.

Please list any serious or ongoing illnesses, operations or disabilities with dates.

Please tick if you have ever suffered from of any of the following.

Are you currently taking any medication?.

If yes please list.

Are you allergic to any tablets or substances?.

If yes please list.

Are you currently under any hospital?.

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes). Please give dates of your last booster vaccination for: Flu.

 Format: dd/mm/yyyy

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes). Please give dates of your last booster vaccination for: Pneumonia.

 Format: dd/mm/yyyy

Please tick if any close relative has suffered from any of the following.

Are you a carer?.

We offer free screening for Chlamydia for all 16 - 24 year olds. If you would like to have this test please ask the Health Care assistant or reception for a pack..

We are offering all newly registered patients an HIV test. Please indicate below if you would like to have this test. If diagnosed in the early stages HIV infection is a treatable disease..

Female patients only Do you use the.

Have you ever had a cervical smear test?.

If yes, when was your last test?.

 Format: dd/mm/yyyy

What was the result?.

When is your next smear due?.

 Format: dd/mm/yyyy

Have you had a hysterectomy?.

If yes when?.

 Format: dd/mm/yyyy

If yes why?.

Was it a Total Abdominal Hysterectomy?.

Were you advised to continue to have smear tests?.

Have you ever had a breast x-ray/mammogram?.

Was it normal?.

If no, what happened?.

Are you, or could you currently be, pregnant?.

Have you ever been pregnant?.

How many times?.

Have you ever had any miscarriages/terminations?.

If yes, how many: miscarriages.

Terminations.

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