HEALTH QUESTIONNAIRE FOR NEW PATIENTS



HEALTH QUESTIONNAIRE FOR NEW PATIENTS

Drs Laurence Leaver, Mark O’Shea, Joanna Lambert, & Shahzadi (Harper) Jericho Health Centre, Oxford OX2 6NW.

|Surname | |Preferred Title | |Male /Female/ Other |

|Forename | |Date of Birth | |

|Oxford Address | |Occupation | |

| | |Who else could we contact in an emergency? |

| | |Name |

| | |Relationship |

| | |Contact Details |

|Phone(s): | | |

|E-mail: | |

Have you ever suffered from any of the following? Please give details:

|Condition |Yes/No |Condition |Yes/No |Condition |Yes/No |Condition |Yes/No |

|High Blood Pressure | |Asthma (see below) | |Epilepsy | |Cancer | |

|Heart Disease | |Chronic Lung Disease | |Migraine | |Thyroid Disease | |

|Atrial Fibrillation | |Depression / Anxiety | |Osteoporosis | |HIV | |

|Stroke/TIA | |Eating Disorder | |Coeliac Disease | |Learning Disability | |

|Arterial Disease | |Dementia | |Arthritis | |Other Disability | |

|Diabetes | |Other Mental Health problem | |Chronic Kidney Disease | | | |

|If Yes please give date(s), details and the name/hospital of any specialist you have been seeing |

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For those with asthma please answer:

|Have you had difficulty sleeping because of your asthma symptoms (including cough)? |Yes/No |

|Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? |Yes/No |

|Has your asthma interfered with your usual activities (e.g. housework, work/school etc.)? |Yes/No |

Please list any other past or current significant illnesses, injuries or operations not detailed above:

|Date: |Condition/Operation/Injury |Date: |Condition/Operation/Injury |

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Do you have any allergies? (in particular to any medicine). If yes please specify.

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Please list any prescribed or purchased medication: include inhalers, creams, contraceptives pills etc. (state brand & dose).

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|Lifestyle |If YES please provide details |

|Do you smoke |Yes/No |___ cigarettes/day, or ___ g tobacco/wk |

|Did you smoke in the past? |Yes/No |Date quit: |

|Do you use any “street” or illegal drugs? |Yes/No | |

|Do you keep to a special diet? |Yes/No | |

|How much do you exercise? |Sport(s): |Frequency & Duration: |

|Please tell us your current |Height |cm |____ ft ____ in |BMI = |

| |Weight |Kg |____ st ____ lb | |

|Blood Pressure if known |/ |mm Hg |Date recorded | |

|Alcohol Questions |Score |Your Score |

| |

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/Illness |Which relative(s) affected |Dates |

| | | |

| | | |

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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 MMR | |Typhoid | |

|Diptheria Booster | |*Second MMR | |First Hepatitis A | |

|Pertussis Booster | |*1st Meningitis C | |Second Hepatitis A | |

|Polio Booster | |*Meningitis ACWY | |Yellow Fever | |

|3rd HPV | |Pneumococcal | |Hepatitis 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 Asian | |Black/Black British | |British/mixed British | |

|Indian | |Caribbean | |Irish | |

|Pakistani | |African | |White & Black Caribbean | |

|Bangladeshi | |Any other Black background | |White & Black African | |

|Chinese | |Other ethnic category (state) | |White & Asian | |

|Ethnic category not stated | | | |Other 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

|Date |Weight |Height |BP |Urine |

|Smoking |Alcohol |Chlamydia |Diet |Exercise |

|Consent for |SCR and/or OCS |Care.data |email |Text/ voicemail |

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