ࡱ>  bjbjR|R| B00Q\ \ 8TV|*P(OOOOOOO$RRUOOO"""O"O""JXMls ,"GL(OO0*PoLlUN8UPMM^U9N\""'YOO!B*PU\ |: HEALTH QUESTIONNAIRE FOR NEW PATIENTS Drs Laurence Leaver, Mark OShea, Joanna Lambert, & Shahzadi (Harper) Jericho Health Centre, Oxford OX2 6NW. SurnamePreferred TitleMale /Female/ OtherForenameDate of BirthOxford Address Occupation Who else could we contact in an emergency? Name Relationship Contact DetailsPhone(s):E-mail:Have you ever suffered from any of the following? Please give details: ConditionYes/NoConditionYes/NoConditionYes/NoConditionYes/NoHigh Blood PressureAsthma (see below)EpilepsyCancerHeart DiseaseChronic Lung DiseaseMigraineThyroid DiseaseAtrial FibrillationDepression / AnxietyOsteoporosisHIVStroke/TIAEating DisorderCoeliac DiseaseLearning DisabilityArterial DiseaseDementiaArthritisOther Disability DiabetesOther Mental Health problemChronic Kidney DiseaseIf Yes please give date(s), details and the name/hospital of any specialist you have been seeing For those with asthma please answer: Have you had difficulty sleeping because of your asthma symptoms (including cough)?Yes/NoHave you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?Yes/NoHas your asthma interfered with your usual activities (e.g. housework, work/school etc.)?Yes/NoPlease list any other past or current significant illnesses, injuries or operations not detailed above: Date:Condition/Operation/InjuryDate:Condition/Operation/InjuryDo you have any allergies? (in particular to any medicine). If yes please specify. Please list any prescribed or purchased medication: include inhalers, creams, contraceptives pills etc. (state brand & dose).  LifestyleIf YES please provide detailsDo you smokeYes/No___ cigarettes/day, or ___ g tobacco/wkDid you smoke in the past?Yes/NoDate quit:Do you use any street or illegal drugs?Yes/NoDo you keep to a special diet?Yes/NoHow much do you exercise?Sport(s): Frequency & Duration:Please tell us your current Heightcm____ ft ____ inBMI =WeightKg____ st ____ lbBlood Pressure if known/mm HgDate recorded Alcohol QuestionsScoreYour Score01234How often do you have an alcoholic drink?NeverMonthly or less2 4 times per month2 3 times per week4 + times per weekHow many units of alcohol* do you have on a typical day, when you are drinking?1 23 - 45 - 67 - 810 +How often do you have 6 (for women) or 8 (for men) or more units* of alcohol on one occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost daily*one unit is approx. 250ml of beer, a very small glass of wine, or a measure of spirit: see  HYPERLINK "http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx" www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx Please give details of any illnesses which run in your family, or affect your immediate family (parents, brothers, sisters or your children). Include Heart Disease (diagnosed under the age of 60); Thrombosis (DVT or PE), Breast, Ovarian, Colon, Prostate and Melanoma (Skin) Cancer; Thalassaemia or Sickle Cell, Coeliac Disease, Osteoporosis, serious mental illnesses and any others you feel are relevant. Disease/IllnessWhich relative(s) affectedDates Please tell us when you had these vaccinations: (e.g.Oct 95 or as child or never) *=very important for University Students Tetanus Booster*First MMRTyphoidDiptheria Booster*Second MMRFirst Hepatitis APertussis Booster*1st Meningitis C Second Hepatitis APolio Booster*Meningitis ACWYYellow Fever3rd HPVPneumococcalHepatitis B Other(s)Are you a carer for someone (A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support.)? YES/NO Do you have a carer? YES/NO If YES provide name/contact details . Are you a Reservist in the UK Armed Forces? YES/NO Are you a Veteran of the UK Armed Services? YES/NO Is there anything else you would like to tell us about your health? First Language (state): Ethnic Origin- please tick (NB these categories are provided by UK government, not chosen by us) Asian/ British AsianBlack/Black BritishBritish/mixed BritishIndianCaribbeanIrishPakistaniAfricanWhite & Black CaribbeanBangladeshiAny other Black backgroundWhite & Black AfricanChineseOther ethnic category (state)White & AsianEthnic category not statedOther mixed background FOR WOMEN If you have had a cervical cytology test (Pap smear), please tell us: Date of last smear: .Was it normal? YES/NO When is your next smear due? . What method (or brand) of birth control (contraception) do you use? . How many pregnancies have you had? What happened in each pregnancy (e.g. caesarian, miscarriage, termination)? Please include dates: Have you had a hysterectomy (womb removed)? YES/NO. If YES, date . For Practice Use DateWeightHeightBPUrineSmokingAlcoholChlamydiaDietExerciseConsent forSCR and/or OCSCare.dataemailText/ voicemail     LBL/JHC/new patient quest. Version  DATE \@ "dd/MM/yy" 07/10/16 %&FHNWXZclJ K S T W X a b ¾¾±¤yrnrnrnrh= h/h= h/h,Qh#Sh)hD^J hKhDh)h}^J hKh}h)h`OJQJ^Jh)hKOJQJ^JhS+ hKhKh~h'O h}h'O h'Oh'O h}hxchxc h}h}hKh} hO h,Q+& $IfgdK $Ifgd)$a$gd}gd2.%%% $Ifgd)kd$$Ifl    r"* C t0    644 lap2ytS+=44 $IfgdT'kd$$Ifl    \*  t0    644 lap(ytS+ $Ifgd)9kd$$Ifl4    \*``  t0    644 lap(yt} $Ifgd)( - : J K U V H? $Ifgd}kd$$Ifl4    |F*  ` t0    6    44 lapyt} $Ifgd) $IfgdKV W X ` a Qkdc$$Ifl4    AF*  t0    6    44 lapyt} $Ifgd)a b toff]]]]]] $IfgdM $IfgdKgdKkd&$$Ifl4    0*  t0    644 lapytD  ! ' ) * 9 M Y h j k ~    & ( ) 3 N P f j k  I R   »Ʊƪƪƪƪ h+hw* h+h+hw*h+56 h/h#Sh#Sh+ h/h+h h/h+^J h/h hw* h/h=h/h+6]^Jh=@ kd$$Ifl4    ִ4 $ &*v                      0        4 laf4yt+     ! ( ) $IfgdK $IfgdM) * kd$$Ifl4    ִ4 $ &*v              0        4 laf4yt+* 8 9 N O X Y i j $IfgdK $IfgdMj k kdC$$Ifl4    ִ4 $ &*v      0        4 laf4yt+k  $IfgdK $IfgdM kd $$Ifl4    ִ4 $ &*v      0        4 laf4yt+ $IfgdK $IfgdM kd $$Ifl4    ִ4 $ &*v      0        4 laf4yt+   ' ( $IfgdK $IfgdM( ) kd9 $$Ifl4    ִ4 $ &*v      0        4 laf4yt+) 2 3 O P g h i j $IfgdK $IfgdMj k kd $$Ifl4    ִ4 $ &*v              0        4 laf4yt+k J Q $Ifgd+gdw*fkd?$$Ifl4    K* 0    4 laf4yt+ $Ifgd= Q R xoo $Ifgd+kd$$Ifl0"'* t0644 lapytM  & xoo $Ifgd+kdk$$Ifl0"'* t0644 lapytM   % ' 3 6 J M X o z 5678S`jlsߡ˂ߏ{{ h/hMh/hKOJQJ^JhM h/hw* h/hXO h/h+1uhvhw*hDh/h+OJQJ^JhKOJQJ^Jh/h,QOJQJ^J hS+hS+hK h/hb=hS+ h/h,Qh+ h+h+/& ' xsjjjj $IfgdKgdKkd$$Ifl0"'* t0644 lapytM f]]]] $IfgdFkd$$Ifl    \G*        0    64 la f]]]] $IfgdFkd$$Ifl    \G*    0    64 la f]]]] $IfgdFkd$$Ifl    \G*    0    64 la 567faXX $IfgdFgdKkd$$Ifl    \G*        0    64 la78 $IfgdFgdKckd$$Ifl4*064 laf4~~ $IfgdFxkdn$$Ifl    0*  0    64 laytK~~ $IfgdFxkd$$Ifl    0*  0    64 laytKyy $IfgdKgdKxkdp$$Ifl    0*  0    64 laytK%vmdm $IfgdM $IfgdKkd$$Ifl    0*R  6   t0    644 lapytM$%&@AGHSTlw|~!"%()*04CEF]^efsuvwxÿػh}h)hKOJQJ^JhKhK0J h/hKhKhP h/hM hKhD hMhMha)hD5\ha)hD5hMhD h/hD hM5\<%&AHS^ULU $IfgdM $IfgdKkd$$Ifl    Ff*  6  t0    6    44 lapyt+ST~^ULU $IfgdM $IfgdKkdc$$Ifl    Ff*6 t0    6    44 lapyt+^ULU $IfgdM $IfgdKkd$$Ifl    Ff*6 t0    6    44 lapyt+^ULLL $IfgdK $IfgdMkd$$Ifl    Ff*6 t0    6    44 lapyt+"^UUI= $$Ifa$gd) $$Ifa$gd) $IfgdKkd$$Ifl    Ff]*H t0    6    44 lapytP"()#kd?$$Ifl4    rV f *`` t0    644 lap2yt+ $IfgdK)*14DE $IfgdK $$Ifa$gd) $$Ifa$gd) $IfgdKEF^,# $IfgdKkd+$$Ifl4    rV f *   t0    644 lap2yt+^`ftu $IfgdK $$Ifa$gd)uvwy.)'gdKkd$$Ifl    rf n*rs t0    644 lap2yt+xyz*+4D67Ʒηᚊ}m}f}f}f} h/h,Qh/h,Q6OJQJ]^Jh/h,QOJQJ^Jh/hb=5OJQJ\^Jh/h,Q5OJQJ\^Jhp,=hp,=0JCJaJjhp,=hp,=CJUaJhp,=CJaJhp,=hp,=CJaJh.hp,=hkhp,=^J hkhb= hkhDhKhD(yJkd$$Ifl4F1"'* t06    44 lapytk $IfgdK $IfgdD)*+{Ff& $Ifgdp,=Ff#Ff $IfgdK567wriii $IfgdFgdKqkd+$$Ifl* t0644 lap ytM $Ifgdp,=Ff) $IfgdK vmmm $Ifgdpkda,$$IflF #*d        06    4 laytpvmmm $Ifgdpkd\-$$IflF #*d     06    4 laytpvmmm $IfgdpkdW.$$IflF #*d   06    4 laytpl|}vqh_h___ $IfgdK $Ifgd)gd`kdR/$$IflF #*d      06    4 laytpBbkl46d/79:MUVzŸ~wp~wleaZVZVZVZVh/% h/%h/%hK hKhDhD h{]h{] h{]h/% h{]hDh{]h{]CJOJQJaJh{]h{]5OJQJ\h{]hD5h)hKH*OJQJ^Jh)hKOJQJ^Jhb=OJQJ^Jh`OJQJ^JhKOJQJ^Jh/hb=OJQJ^Jh/hb=5OJQJ\^JkdM0$$Ifl    ֈ Dp#*,,,,,, t0    644 lap<yt) $IfgdK $Ifgd)kd1$$Ifl    ֈ Dp#*,,,,,, t0    644 lap<yt) $IfgdK $Ifgd)kd1$$Ifl    ֈ Dp#*,,,,,, t0    644 lap<yt)#$12 $IfgdK $Ifgd)23kdx2$$Ifl    ֈ Dp#*,,,,,, t0    644 lap<yt)3;<IJWX $IfgdD $IfgdK $Ifgd)XYkd13$$Ifl    ֈ Dp#*,,,,,, t0    644 lap<yt)Ybcd:V<dMMHHHgdDd-DM [$\$gd{]kd3$$Ifl    0*,# t0    644 lapyt) $IfgdK $Ifgd)(:;<=KSTUbkqͻsbsQs@ hO 5>*CJOJQJ^JaJ h`5>*CJOJQJ^JaJ h\5>*CJOJQJ^JaJ hK5>*CJOJQJ^JaJ&h/hO 5>*CJOJQJ^JaJ&hKhO 5>*CJOJQJ^JaJhO >*CJOJQJ^JaJ#hO hO >*CJOJQJ^JaJ&hO hO 5>*CJOJQJ^JaJh/hK5OJQJ\^Jh,QhF h/h,Q<=U $If^gd)^gdKgdO   '(@ABNOjk-34OYZ޻hKhKOJQJ^Jh/h,QOJQJ^JhKOJQJ^J&h/h,Q5CJOJQJ\^JaJ hK5>*CJOJQJ^JaJ#h)hK>*CJOJQJ^JaJh)hK5OJQJ^J&h)hK5>*CJOJQJ^JaJ/kd4$$Ifl    ֈ E&* t0    644 lap<yt)   $If^gd)kd5$$Ifl    ֈ E&* t0    644 lap<yt)'(@A $If^gd)ABkd}6$$Ifl    ֈ E&* t0    644 lap<yt)BNOjk $If^gd)kdw7$$Ifl    ֈ E&* t0    644 lap<yt) $If^gd)kdq8$$Ifl4    ֈ E&*`` t0    644 lap<yt) $If^gd)kdx9$$Ifl4    ֈ E&*   t0    644 lap<yt)F4}}}xo $IfgdKgdK&$d%d&d'dNOPQgdO &$d%d&d'dNOPQgdK*$d%d&d'dNOPQ^gdO h^hgdK Zemn 4TUY~  EU`ajkpqȻ黤ܐ}}yuyuyuyuyn h}5\h#Sh} h/hththb=hK h/hb=h/hNOJQJ^Jh,QOJQJ^JhKhn8OJQJ^JhKh,QOJQJ^JhKhKOJQJ^J hKhKh/h,QOJQJ^JhKOJQJ^Jh/hKOJQJ^J+  $IfgdK$,60''' $IfgdKkd:$$Iflr/e"* t0644 lap2ytM6;DER'kd7;$$Iflr/e"* t0644 lap2ytM $IfgdKRakq $Ifgd#S $IfgdK0+))gd}kd;$$Iflr/e"* t0644 lap2ytMƺƫ֧hFhQ4fCJaJmHnHsH uhFCJaJmH sH jhFCJUaJmH sH hFCJaJhS+hFCJaJmH sH h7jh7U h/hS+gd} @P&P1h:pK/ =!"#$%B Dp$$If!vh#vM#v#v#v#v:V l t0    6555 5C5p2ytS+$$If!vh#vM#v#v#v :V l t0    6555 5p(ytS+$$If!vh#vM#v#v#v :V l4 t0    6++555 5p(yt}$$If!vh#vM#v#v:V l4| t0    6+++555 pyt}$$If!vh#vM#v#v:V l4A t0    6+555 pyt}$$If!vh#vi#v:V l4 t0    6+5 5 pytD$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  /  /  /  /  /  /  /  /  /  /  /  /  /  /  /  4f4yt+$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  /  /  /  /  / /  /  /  /  /  /  / 4f4yt+P$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  / /  /  /  /  / 4f4yt+P$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  / /  /  /  /  / 4f4yt+P$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  / /  /  /  /  / 4f4yt+l$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  / / /  /  /  /  / / 4f4yt+$$If!vh#v#vP#vN#vR#v#vU#v#v:V l40    5v5555555/  /  /  /  /  /  /  /  /  /  /  / /  4f4yt+$$If!vh#v+:V l4K0    5/  4f4yt+$$If!vh#v'#vz:V l t0655pytM$$If!vh#v'#vz:V l t0655pytM$$If!vh#v'#vz:V l t0655pytM$$If!vh#v1#vS#v/#vU:V l0    65555/  /  /  / /  /  /  / 4$$If!vh#v1#vS#v/#vU:V l0    65555/  /  / /  /  /  / /  4$$If!vh#v1#vS#v/#vU:V l0    65555/  /  / /  /  /  / /  4$$If!vh#v1#vS#v/#vU:V l0    65555/  /  / /  /  /  / /  4$$If!vh#v+:V l4065/ 4f4$$If!vh#v:V l0    65 4ytK$$If!vh#v:V l0    65 4ytK$$If!vh#v:V l0    65 4ytK$$If!vh#vU#v:V l t0    65R56 /  pytM$$If!vh#v#v#v:V l t0    65556 /  pyt+$$If!vh#v#v#v:V l t0    65556 pyt+$$If!vh#v#v#v:V l t0    65556 pyt+$$If!vh#v#v#v:V l t0    65556 pyt+$$If!vh#v#v #v?:V l t0    6555HpytP$$If!vh#v #v#v#v #v :V l4 t0    6++5555p2yt+$$If!vh#v #v#v#v #v :V l4 t0    6++5555p2yt+$$If!vh#v#v#vc#ve#v :V l t0    6555r5s5p2yt+$$If!vh#v#v#vz:V l4 t06++,5/ pytk$$If!vh#v#v#v#vZ#v#v#vz:V l4 t06++,5/ pFytkkd$$Ifl4֞1:""'* t0644 lapFytk$$If!vh#v#v#v#vZ#v#v#vz:V l t06,5/ pFytkkd"$$Ifl֞1:""'* t0644 lapFytk$$If!vh#v#v#v#vZ#v#v#vz:V l t06,5/ pFytkkd%$$Ifl֞1:""'* t0644 lapFytk$$If!vh#v#v#v#vZ#v#v#vz:V l t06,5/ pFytkkd($$Ifl֞1:""'* t0644 lapFytk$$If!vh#v+:V l t06,5/ p ytM$$If!vh#v#v.#v:V l065d5 5/  /  / /  /  /  / 4ytp$$If!vh#v#v.#v:V l065d5 5/  / / / /  /  / 4ytp$$If!vh#v#v.#v:V l065d5 5/  / / / / / /  4ytp$$If!vh#v#v.#v:V l065d5 5/  /  / / / /  /  4ytp$$If!vh#v,:V l t0    65,p<yt)$$If!vh#v,:V l t0    65,p<yt)$$If!vh#v,:V l t0    65,p<yt)$$If!vh#v,:V l t0    65,p<yt)$$If!vh#v,:V l t0    65,p<yt)$$If!vh#v,#v#:V l t0    65,5#pyt)$$If!vh#v #vW#v #v`#v] #v:V l t0    6555555p<yt)$$If!vh#v #vW#v #v`#v] #v:V l t0    6555555p<yt)$$If!vh#v #vW#v #v`#v] #v:V l t0    6555555p<yt)$$If!vh#v #vW#v #v`#v] #v:V l t0    6555555p<yt)$$If!vh#v #vW#v #v`#v] #v:V l4 t0    6++555555p<yt)$$If!vh#v #vW#v #v`#v] #v:V l4 t0    6++555555p<yt)$$If!vh#v#v:V l t0655p2ytM$$If!vh#v#v:V l t0655p2ytM$$If!vh#v#v:V l t0655p2ytM^! hH02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH L`L Normal$CJOJQJ^J_HaJmH sH tH 8@8  Heading 1$@&>*H@H  Heading 2$h@&^h >*CJaJ`@`  Heading 3!$$d@&N^5>*CJ\aJ@@@  Heading 4$@& >*CJaJN@N  Heading 5$@&^5>*CJ\aJH@H K Heading 6$$@&a$5CJ\aJF@F  Heading 7 $x@&5CJ\aJDA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List :B@: Body Text 56\]44 Header  !4 @4 Footer  !PC@"P Body Text Indent ^ >*CJaJ0>@20 Title$a$>*jCj LA Table Grid7:V0<@R< J Balloon TextCJaJRoaR JBalloon Text CharCJOJQJ^JaJtH 6U`q6 K Hyperlink >*B*ph>O> K table text LLOJQJDOD K headings LL5OJQJ\^JToT Ktable text LL CharCJOJQJ^JaJtH @@ K List Paragraph ^VoV Kheadings LL Char5CJOJQJ\^JaJtH .X`. 2@Emphasis6]B/B 2apple-converted-spaceZ^@Z {]0 Normal (Web)dd[$\$CJOJQJ^JaJtH *W`* {]`Strong5\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  PPPS  xZ(3>FQS`fV a ) * j k ( ) j k Q & 7%S")E^uy23XY<AB6R !"#$%&')*+,-./012456789:;<=?@ABCDEGHIJKLMNOPRTUVWXYZ[\]^_abcdeg  X/DMS8@0(  B S  ?##6 ?9*urn:schemas-microsoft-com:office:smarttagsplace V"$9; $ HMajWXYYcl(b)*NO()hJR'5AT~wwy* { 6 l dd/7:UVR`FNWXYY``clKSbbwwdd/7:UVU`ajkpq@3xb|3LkLriN;.2()(Цl e])aTN+&kP.ԲnqG<CFIG6IS*WVJ5i`~pOlGH[po^`56CJOJQJ^JaJo(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h^`o(.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(h^`o(.hpp^p`.h@ L@ ^@ `L.h^`.h^`.hL^`L.h^`.hPP^P`.h L ^ `L.h88^8`.h^`.h L ^ `L.h  ^ `.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L. ^`OJPJQJ^Jo(^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hHhhh^h`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(hhh^h`5o(hH.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h88^8`o(.h^`.h L ^ `L.h  ^ `.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L.h88^8`o(.h^`.h L ^ `L.h  ^ `.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L.h^`56CJOJQJ^JaJo(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h^`56CJaJo(hH.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.6IS])5i`|3WV eOlH[pokP.@3N+(iqG<;IGCiȔ        D"E^                 f<-Ad3y8 &z277 ;7n8p,=S=b=>@/Bs5D OXO,QQGRZPR#Su[`~aNbQ4fR?io"l8eqt+1u(B}~`L9=66.YN LAJ\Z}PF MS+T'BM'O+2K& {]/%)xc@@Unknown G*Ax Times New Roman5Symbol3. *Cx ArialA. Arial Narrow;. *Cx Helvetica5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"hd=Jd=JFkDgt %t %!4yy2QHX?R?i2!xx %HEALTH QUESTIONNAIRE FOR NEW PATIENTSValerie J Maher Windows UserP            Oh+'0x  ( 4 @ LX`hp(HEALTH QUESTIONNAIRE FOR NEW PATIENTSValerie J Maher Normal.dotmWindows User2Microsoft Office Word@@|@8i @8i t՜.+,D՜.+,P  hp|  NHS% y &HEALTH QUESTIONNAIRE FOR NEW PATIENTS Title 8@ _PID_HLINKSA=s<http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghjklmnopqrstuvwxyz{|}~Root Entry F`os Data i<1TableUWordDocumentBSummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q