New Patient Questionnaire - Birchwood Medical Practice

Thank you for submitting a new patient registration form.

Please complete and submit our patient questionnaire which is also required as part of our registration process to support continuity of patient care.

Registration Details

Name

Prefix First Middle Last

Date of Birth

Address

Street Address Address Line 2 City County Postal Code Country

Phone

Email Optional

Do you consent to communication by Email?

Do you consent to communication by text?

Communication

Is English your first language?

Do you need an interpretor? Optional

For which language do you need an interpreter for?

Ethnicity

Please state

Height and Weight

What is your current height?

What is your current weight?

Consumption

How many units of Alcohol do you consume in 1 Week?

Health and Fitness

How many sessions a week would you say you exercise?

Carer Information

Are you a carer? Optional

Who is it that you care for?

Name and D.O.B

Are you cared for? Optional

Who is it that cares for you?

Name and D.O.B

Smoking Status

Do you smoke?

What type do you smoke? Optional

When did you stop smoking? Optional

How many cigarettes or how many grams of tobacco do you smoke a day? Optional

General History

Are you allergic to anything?

If yes, then what are your allergies? Do you need specialised medication?

What regular medication are you currently taking (including the pill)?

Medication. Dosage. Frequency

Do you have/ have you had any serious illnesses, operations or admissions to hospital?

Date. Problem

Family History

Does any of your family have any past medical history?

Which family member has Ischemic Heart Disease over 60?

Which family member has Ischemic Heart Disease under 60?

Which family member has CVA/ Stroke?

Which family member has Diabetes?

Which family member has Asthma?

Which family member has Gastrointestinal Tract Cancer?

Which family member has breast cancer?

Please can you take the time to fill out the below alcohol consumption questionnaire

Do you drink alcohol? Optional

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Optional

How often during the last year have you failed to do what was normally expected from you because of your drinking? Optional

How often during the last year have you been unable to remember what happened the night before because you had been drinking? Optional

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? Optional

How often do you have a drink containing alcohol? Optional

How many units of alcohol do you drink on a typical day when you are drinking? Optional

How often during the last year have you found that you were not able to stop drinking once you had started? Optional

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Optional

How often during the last year have you had a feeling of guilt or remorse after drinking? Optional

Have you or somebody else been injured as a result of your drinking? Optional

DO YOU NEED INFORMATION IN A DIFFERENT WAY?

We can provide information in different ways if you have a sight and/or hearing impairment and need information in an accessible format.

Do you need this? Optional

Please specify

Braille grade 1 Optional

Braille grade 2 Optional

Email Optional

Large print 22 point Optional

Large print 24 point Optional

Large print 28 point Optional

Audio version Optional

Easy read format Optional

Email Optional

Patient Participation Group (PPG)

A Patient Participation Group (PPG) is a group of volunteer patients and practice staff who meet continually to discuss and improve services together”

Would you like to be part of our PPG? Optional

I have filled in this form on behalf of Optional