New patient questionnaire – Ribblesdale Medical Practice

Step 1 of 4

25%

Contact Details
Name
First Name Surname
Telephone - Home
Telephone - Mobile
Telephone - Work
Email Address
Next of Kin (and relationship)
Contact Number for Next of Kin
Do you need an interpreter? If yes, which language?
- Yes
- No
*PLEASE BE AWARE THAT THIS WILL EXCLUDE YOU FROM APPOINTMENT REMINDERS*
- If you would NOT like to receive any communication by SMS text message please tick here
- If you would NOT like to receive any communication by email please tick here
*PLEASE BE AWARE THAT THIS WILL EXCLUDE YOU FROM APPOINTMENT REMINDERS*

Health Information

Do you have any current medical conditions i.e. Diabetes, Asthma, Stroke, High blood pressure, HIV Positive, Dementia, Ischaemic Heart Disease, Learning Difficulties, Mental Health Problems, Other?
Please use the plus sign (+) to add rows as needed.
Condition Treatment

Please indicate any ALLERGIES.
Please use the plus sign (+) to add rows as needed.
Medication Food Other

Smoking Status
Do you smoke?
Yes, cigarettes
Yes, roll my own
No, never
Ex smoker

Help to stop smoking is available call 0800 856 3409 or 020 3049 5791, or email gst-tr.stopsmokinglambeth@nhs.net.
If you smoke cigarettes, how many do you smoke per day? If you roll your own, how many grams do you smoke per week? If you are an ex smoker, how long has it been since you quit?
Alcohol
How often do you have a drink containing alcohol?
Never (1)
Monthly or less (1)
2-4 times a week (2)
2-3 times a week (3)
4+ times a week (4)
How many standard* drinks containing alcohol do you have on a typical day when you are drinking?
1-2 (0)
3-4 (1)
5-6 (2)
7-9 (3)
10+ (4)
How often do you have six or more standard* drinks on one occasion?
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily/almost daily (4)
Please use this box to record the total score (the numbers in brackets above) for the 3 questions.
How many units* of alcohol, if any, do you drink in a typical week? If you are unsure then tell us what you drink below.
*One unit/standard drink = ½ pint of ordinary beer/lager/cider or a single measure of spirits or a standard glass of wine, or a small glass of sherry/vermouth/aperitif

Carers
If you provide help for someone with a disability or illness, or are reliant on help to live your daily life, please ask for our CARERS FORM.
I am a main carer
I have a carer
Family History

It is important for us to know whether you have a family history of heart disease (IHD) (over 60), heart disease (IHD) (under 60), stroke, hypertension, diabetes (insulin or non insulin), asthma, breast cancer, cancer, or other. If yes, please list the condition, the relative and whether they are on your mother's side (maternal) or father's side (paternal).
Please use the plus sign (+) to add more rows as needed.
Condition Relative Maternal/Paternal

For Women

Please give details of your last cervical screening.
Date taken GP/Clinic name Result (if known) Recall date (if known)

Have you had a hysterectomy?
Yes
No
If yes, please give the date of the surgery.
HIV Testing
All new patients registered at this practice are being offered an HIV test.
Yes
No
If yes, you will need to make an appointment to have a blood test at the surgery.
Chlamydia & Gonorrhoea Screening
Would you like a Chlamydia Test?
Yes
No
If yes, you will need to provide a specimen of urine.

New Registration Health Check
We offer all patients a basic health check with our Health Care Assistant, measuring height, weight ,BP etc.
Yes, please
No, thanks
Ethnicity
Please indicate your ethnicity. For all of the options listed below, please choose ONE only
White
British
Traveller
Asian or British Asian
Indian
Pakistani
Bangladeshi
Mixed Race
White & Caribbean
White & African
White & Asian
Black / Black British
Caribbean
African
Chinese
Chinese
If your ethnicity has not been listed above, please indicate it below.
What language do you prefer to read?
I can read English.
Yes
No
I was given help in completing this form as I do not read any language.
Yes
No
Do you need large print?
Yes
No
Do you have a hearing problem?
Yes
No
Do you rely on lip reading?
Text Phone or Minicom
British Sign Language
Makaton
I do not rely on lip reading
Please indicate your religion below.

Please list the names of all the people who are living in the same house as you.
Please use the plus sign (+) to add more rows as needed.
Surname Forename Date of Birth Relationship to you If you are under 16, does this adult have parental responsibility?

Summary Care Record
You have a choice of what information you share. Only Authorised healthcare staff can view your SCR with your permission. The information shared will be solely for the benefit of your care. Please indicate your choice below. More information is available on https://digital.nhs.uk/services/summary-care-records-scr or you can talk to your GP Practice or call NHS Digital on 0300 303 5678.
Express consent to share Medication, Allergies and Adverse Reactions only.
Express consent to share Medication, Allergies and Adverse Reactions and Additional Information e.g. Illnesses and health problems, vaccination you have had.
Express DISSENT (OPT OUT) – select this if you DO NOT want to share information with other healthcare professionals .

Step 1 of 4

Contact Details

Health Information

Smoking Status

Alcohol

Carers

Family History

For Women

HIV Testing

Chlamydia & Gonorrhoea Screening

New Registration Health Check

Ethnicity

Summary Care Record