Activity How often do you take moderate to vigorous exercise for at least 20 minutes? Exercise physically No regular exercise Once per week Twice per week Three or more times impossible per week Moderate to vigorous exercise is activity that makes you sweat or raise your pulse such as swimming, cycling, brisk walking etc. Alcohol How often do you have a drink that Never Monthly or 2-4 times 2-3 times 4+ times contains alcohol? less per month per week per week How many standard alcoholic drinks 1-2 3-4 5-6 7-8 10+ do you have on a typical day when you are drinking? How often do you have 6 or more Never Less than Monthly Weekly Daily or standard drinks on one occasion? Monthly almost daily For office use only - 0 1 2 3 4 Smoking Status Which of the following best describes you? Never Smoked Ex-Smoker Current Smoker If you would like help to stop smoking please ask for information on NHS support to quit. Contact the national NHS stop smoking helpline on 0300 123 1044. To book an appointment locally for support to stop smoking call health promotion on 01884 836024, or email: Measurements Height: Weight: Blood Pressure: (please use the Blood Pressure machine in the waiting room or ask at reception to borrow one) Medication Do you take any regular medication? Yes No local pharmacy would you like your prescriptions to be sent to? By Boots (High St) nominating a local pharmacy we will be able to send your prescriptions Crediton Pharmacy (High St) to the pharmacy electronically. This will become your default pharmacy and all medication will be sent Threshers (Next to surgery) here unless you instruct us otherwise. Tesco (Wellparks) If yes, please attach a repeat prescription list and arrange to see a GP to discuss your medication. Allergies Do you have any allergies / drug allergies? Yes No If Yes please specify along with the type of reaction suffered: Carer Do you look after someone who is ill, frail, disabled or mentally ill? Yes No Does someone look after you? Yes No
Activity How often do you take moderate to vigorous exercise for at least 20 minutes? Exercise physically impossible No regular exercise Once per week Twice per week Three or more times per week Moderate to vigorous exercise is activity that makes you sweat or raise your pulse such as swimming, cycling, brisk walking etc. Alcohol How often do you have a drink that contains alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-8 10+ How often do you have 6 or more standard drinks on one occasion? Never Less than Monthly Monthly Weekly Daily or almost daily For office use only - 0 1 2 3 4 Smoking Status Which of the following best describes you? Never Smoked Ex-Smoker Current Smoker If you would like help to stop smoking please ask for information on NHS support to quit. Contact the national NHS stop smoking helpline on 0300 123 1044. To book an appointment locally for support to stop smoking call health promotion on 01884 836024, or email: Measurements Height: Weight: Blood Pressure: (please use the Blood Pressure machine in the waiting room or ask at reception to borrow one) Medication Do you take any regular medication? Yes No local pharmacy would you like your prescriptions to be sent to? By nominating a local pharmacy we will be able to send your prescriptions to the pharmacy electronically. This will become your default pharmacy and all medication will be sent here unless you instruct us otherwise. Boots (High St) Crediton Pharmacy (High St) Threshers (Next to surgery) Tesco (Wellparks) If yes, please attach a repeat prescription list and arrange to see a GP to discuss your medication. Allergies Do you have any allergies / drug allergies? Yes No If Yes please specify along with the type of reaction suffered: Carer Do you look after someone who is ill, frail, disabled or mentally ill? Yes No Does someone look after you? Yes No
New%20Patient%20Health%20Questionnaire.docx