27 BEAUMONT STREET SURGERY - Confidential New Patient Questionnaire Welcome to 27 Beaumont Street Surgery. Please help us by filling in this questionnaire as it may take some time for your previous records to reach us. The information you give will be used to provide you with the best possible medical care. Personal details : Date of registration Title First Surname Mr Mrs Miss Ms Names Date of Mobile No Email Address Name of Subject College Next of Kin details Title Mr Mrs Miss First Surname Ms Name Telephone Relationship No No to you PLEASE NOTE THAT WE USE TEXT MESSAGING AND EMAILING FOR RECALLS AND APPOINTMENT REMINDERS - IF YOU DO NOT WISH US TO CONTACT YOU IN THIS WAY PLEASE TELL A RECEPTIONIST. Height: Weight: Lifestyle: Are you a Yes No If No, Have you ever smoked? Yes No smoker? If Yes, would you like the practice nurse to contact you Yes please No thanks to discuss smoking cessation ALCOHOL - Please answer the following by ticking one answer for each question: Please tick boxes Scoring System Questions 0 1 2 3 4 1. How often do you have a drink that contains Never Monthly or 2-4 Times 2-3 Times per 4+ Times per alcohol? Less per month week week 2. How many standard alcoholic drinks do you have on a typical day 1-2 3-4 5-6 7-9 10+ when you are drinking? 3. How often do you have 6 or more standard drinks Less than Monthly Weekly Daily or on one occasion? Monthly almost daily ADD UP YOUR SCORE If your score for Q1-3 is 5 or more complete the questions on page 3 Past medical history: Please give details of any important illness, operations or of pregnancies Date Details Date Details Date Details Add any other information you would like the doctor to know about Drugs & Treatment If you are taking any drugs or treatment, please detail below : Name of medicine Strength/ Dose Name of medicine Strength/ Dose Name of medicine Strength/ Dose
27 BEAUMONT STREET SURGERY - New Patient Questionnaire Confidential Welcome to 27 Beaumont Street Surgery. Please help us by filling in this questionnaire as it may take some time for your previous records to reach us. The information you give will be used to provide you with the best possible medical care. Personal details : Date of registration Title Mr Mrs Miss Ms First Names Surname Date of Mobile No Email Address Name of College Subject Next of Kin details Title Mr Mrs Miss Ms First Name Surname Telephone No No Relationship to you PLEASE NOTE THAT WE USE TEXT MESSAGING AND EMAILING FOR RECALLS AND APPOINTMENT REMINDERS - IF YOU DO NOT WISH US TO CONTACT YOU IN THIS WAY PLEASE TELL A RECEPTIONIST. Lifestyle: Height: Weight: Are you a smoker? Yes No If No, Have you ever smoked? Yes No If Yes, would you like the practice nurse to contact you to discuss smoking cessation Yes please No thanks ALCOHOL - Please answer the following by ticking one answer for each question: Please tick boxes Scoring System Questions 0 1 2 3 4 1. 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 2. How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ 3. How often do you have 6 or more standard drinks on one occasion? Less than Monthly Monthly Weekly Daily or almost daily ADD UP YOUR SCORE If your score for Q1-3 is 5 or more complete the questions on page 3 Past medical history: Please give details of any important illness, operations or of pregnancies Date Details Date Details Date Details Add any other information you would like the doctor to know about Drugs & Treatment If you are taking any drugs or treatment, please detail below : Name of medicine Strength/ Dose Name of medicine Strength/ Dose Name of medicine Strength/ Dose
Doctors-NPQ.docx