Firrhill Adult New Patient Questionnaire

Title

Name *

Date of Birth *

Previous Surname

Occupation

Who else lives in your household

What is your height? *

What is your weight? *

What is your first language? *

Do you need an interpreter? *

Yes No

Ethnic Group *

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place

Have you ever suffered from? (tick as appropriate)

If yes, please state the year(s) when were you first diagnosed?

Please list any medicines being taken and the amount:

Any prescriptions will be sent to your local preferred pharmacy. Please indicate which Pharmacy you wish to use.

Colinton Mains Pharmacy

Dears Pharmacy (Oxgangs Bank)

Colinton Village Pharmacy

Bruntsfield Pharmacy

Craiglockhart

Other

Lorimer Pharmacy

Are you registered disabled? *

Yes No

If yes, please give details

Do you have any allergies to medication or life threatening food allergies? *

Yes No

If so, which?

If yes to any of these, please state the year(s) when were you first diagnosed?

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

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

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Have you ever had a cervical smear?

Yes No

Are you currently pregnant?

Yes No

If yes how many weeks

Are you immune to Rubella (German Measles)?

Yes

No

Don't Know

Any Tests for Breast Cancer?

Yes No

If yes please give details

If 'yes', please state when, where and the result

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

On an average day how many units of alcohol do you consume. A unit is roughly equivalent to a small glass of wine, a half pint of beer or a single measure of spirit. *

I have had problems in the past drinking excessive amounts of alcohol *

Yes No

How often do you exercise?

Once per week

2 times per week

3 times per week

Every day

I am not able to take any regular exercise

I am unable to leave my house without help

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. *

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

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Signature *

Date *

Firrhill Adult New Patient Questionnaire

Firrhill Adult New Patient Questionnaire

Further Information