New patient questionnaireStep 1 of 425%Contact DetailsName First Name Surname Telephone - HomeTelephone - MobileTelephone - WorkEmail AddressNext of Kin (and relationship)Contact Number for Next of KinDo 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 InformationDo 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.ConditionTreatment Please indicate any ALLERGIES.Please use the plus sign (+) to add rows as needed.MedicationFoodOther Smoking StatusDo 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 firstname.lastname@example.org.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?AlcoholHow 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 CarersIf 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 carerFamily HistoryIt 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.ConditionRelativeMaternal/Paternal For WomenPlease give details of your last cervical screening.Date takenGP/Clinic nameResult (if known)Recall date (if known) Have you had a hysterectomy? Yes NoIf yes, please give the date of the surgery.HIV TestingAll new patients registered at this practice are being offered an HIV test. Yes NoIf yes, you will need to make an appointment to have a blood test at the surgery.Chlamydia & Gonorrhoea ScreeningWould you like a Chlamydia Test? Yes NoIf yes, you will need to provide a specimen of urine. New Registration Health CheckWe offer all patients a basic health check with our Health Care Assistant, measuring height, weight ,BP etc. Yes, please No, thanksEthnicityPlease 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 ChineseIf your ethnicity has not been listed above, please indicate it below.What language do you prefer to read?I can read English. Yes NoI was given help in completing this form as I do not read any language. Yes NoDo you need large print? Yes NoDo you have a hearing problem? Yes NoDo you rely on lip reading? Text Phone or Minicom British Sign Language Makaton I do not rely on lip readingPlease 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.SurnameForenameDate of BirthRelationship to youIf you are under 16, does this adult have parental responsibility? Summary Care RecordYou 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 .