You my find it useful to complete this questionnaire ahead of registering with us- you will also need your medical card or to fill in a form in reception if you are unable to locate it.

Date of registration	……………………..		Patient number	……………………….
LLWYNCELYN PRACTICE NEW PATIENT HEALTH QUESTIONNAIRE
Introduction This document is intended to be completed by patients to provide basic health information. Providing this information will help us to build a picture of your health and needs.
NAME	__________________________		Date of Birth	____________
Place of Birth	__________________________
Address________________________________________________________________
Previous Address__________________________________________________________
Telephone numbers are important for us to keep on your record. We may need to contact you with the result of a blood test or other investigations. It is also useful in the unfortunate rare event of having to rearrange an appointment with you. Please include mobile numbers wherever possible.
Telephone Home	___________________		Mobile	_______________
Work	___________________		Email	________________
Do you have a home entry code system? If so please specify code to enable Doctor or Nurse to enter if house call is required. (This is completely confidential)				Entry Code…………………..
Next of Kin ( + tel No)	______________________________________________________
Any other contact in the event of emergency such as Family or Carer	Name of contact Telephone Numbers

Your Marital Status
Please tick which of the following best describes your ethnic status.
I do not wish to state my ethnic status
British/mixed British			Irish
Welsh			Other White
Pakistani/British Pakistani			Other Asian
White & Black Caribbean			Caribbean
African			White & Black African
White & Asian			Other Black
Bangladeshi/British Bangladeshi			Chinese
Indian/British Indian			Other mixed
Weight			Height
Occupation
Any other information for contacts you would like to add.
Blood pressure	Checked in the last 10 years?			Yes / No
DIET	Do you add salt to your food after cooking?			Yes / No
	Do you have a varied diet including milk, meat, vegetables and fruit?			Yes / No
	Have you had your cholesterol checked?		When…………….	Result if known…………
EXERCISE	How many minutes do your exercise for at a time?
	How many times per week?___
ALCOHOL.	How many units of alcohol do you drink each week? (1 unit = half pint of beer, 1 glass of wine, or a pub measure of spirits)
SMOKING.	Do you smoke?	Yes / No.	If Yes, how many per day?
	If you smoke, how old were you when you started?
EX-SMOKERS.	If you used to smoke, how old were you when you stopped?
	If you used to smoke, how many did you smoke per day?
PASSIVE SMOKING	Are you exposed to smoke at work?	Yes / No.	At home?	Yes / No
FAMILY HISTORY
Is there any of the following in your family (father, mother, brother, sister)
Heart Disease (Heart attacks, angina)	Yes / No	Which family member?	approx age	Before 60………… after 60………
Stroke? (CVA)	Yes /No	Which family member?	approx age
Cancer?	Yes / No.	Which family member?	approx age
	Site of cancer?
Have you ever suffered from any of the following diseases:
Diabetes	Yes/No	High Blood Pressure	Yes/No
Heart Disease	Yes/No	Epilepsy	Yes/No
Asthma	Yes/No	Other serious illness	Yes/No
If yes please give details:
Have you ever had any operation? if so, please give details and approximate dates

Have you any minor recurring problems e.g. hay fever? If so please specify

Are you on any treatment/ medication at present? Please specify

Do you have any allergies? Please Specify

What vaccinations have you had?:
As a child			As an adult
Diphtheria	age if known		Tetanus	How long ago?
German Measles	age if known		Yellow Fever	How long ago?
Polio			BCG
MMR			Hepatitis B
Whooping Cough			Pneumovax
			Yearly Flu Jab
FEMALE PATIENT ONLY
Have you had any children, if so, what are their ages?....
When did you last have a smear test?.....
Have you ever had an abnormal smear?....
If yes, treatment given and when
What form of contraception are you using at present?.
Do you check your breasts Regularly?
Male patients only
Do you check your testicles regularly?
Is there anything else you would like to tell us, that you feel we need to know. Please use the space below to give details.

Thank you for completing this questionnaire. Please hand this to the nurse when you attend for your new patient check

You my find it useful to complete this questionnaire ahead of registering with us- you will also need your medical card or to fill in a form in reception if you are unable to locate it.

Introduction