NEW PATIENT QUESTIONNAIRE Welcome to Woodlands Surgery. The following questionnaire is designed to help us get to know you and aid in the provision of appropriate servi ices. Please answer all questions as fully and honestly as possible. Once completed, please hand in to the receptionist. If you require this information in another format, please ask at rece) Many thanks for your co-operation. ption. Title & Full name: Address: Post Code: Tel No: Date of Birth: Mobile No: Work No: Marital Status: Married! single[_] Divorced[_] Co-Habiting| Widow / widower C White Asian Black Chinese| Other: (please state) Are you a Smoker? Never Smoked Yes / smoker How Many Ex Smoker Alcohol? Yes| No] (On average, how many units per week? 1 unit of alcohol = half pint beer or 1 glass of wine or 1 spirit measure Current Health? Excellent Good| Fair Poorl_] What is your current weight? How tall are you?Are you Disabled? Yes[_] No If Yes, please state your disability To access our services do you need any specific access requirements? (Please specify, wheelchair access, hearing loop etc) Do you have a Learning Disability? Yes[_ | Nof | Are you a Carer Yes| No[ Are you a Military Veteran? Yes No Are you on any medication? Yes[_] No] If so please list or attach your most recent medication re-order slip. 41 3 5 Do you have any allergies? Yes| No] Penicitin[__] Other (please specify): Have you had any major operations (coronary artery bypass, hysterectomy etc) Operation: Date:Please indicate below if you, or a close family relative, have any of the listed conditions: PH = Personal History FH = Family History PH FH Asthma Atrial Fibrillation Cancer Chronic Kidney Disease Chronic Obstructive Airways Disease (COPD) Coronary Heart Disease (CHD) Dementia Diabetes Epilepsy Heart Failure Hypertension Hypothyroidism Mental Health Problems (Psychoses / Bipolar / etc) Stroke / TIA Have you seen a dooctor at this surgery before? Yes|_] No| Please supply the named and telephone number of your previous GP. Name: Tel No: Signed: Date: On-line services are available, please contact the surgery 6 weeks after registration to obtain details. Thank you for completing this questionnaire. All information given is confidential and forms part of your medical record. You will shortly receive a welcome pack, confirmation of registration with the practice and an invitation for you to attend for a New Patient Check. When attending for this, please bring along a sample of your urine. For Office Use: Application processed Signed: Updated 6/16