New Patient Health Form- Avenham Surgery

Please note this form has to be completed in full for us to register you at this Surgery

Name 
 
Date of Birth

Nationality/ Ethnic origin

Religion

Next of kin

Name

Address

Telephone number 
Relationship

If we require to contact you urgently and have been unable to are you happy for us to contact your NOK who is named on this form

Do you care for another person or are you a registered carer:        Yes/No

If Yes please give the name of the person:

Are you a veteran:                    Yes/No

The next set of questions relate to your health please complete as fully as possible.

Your Height:					Your Weight:

Do you smoke: 		Yes/No

If yes how many/much a day:
If you wish to get help in stopping smoking ask at reception for the Quit Line number.

At what age did you start smoking:

Are you an Exsmoker:		Yes/No
Approximate date of stopping:

Do you drink:			Yes/No
If yes how much per week:

The FAST Test – please circle one answer to each question

1. How often do you have eight or more drinks on one occasion?

Never   	 Less Than Monthly	     Monthly   	  Weekly 	   Daily or Almost Daily

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never 	    Less Than Monthly 	   Monthly   	Weekly    	Daily or Almost Daily

3. How often during the last year have you failed to do what was normally expected of you because of your drinking?

 Never	    Less Than Monthly	     Monthly	    Weekly	     Daily or Almost Daily

4. Has a relative or friend, a doctor or other health worker been concerned about your drinking or suggested you cut down?

No 	   	Yes, but not in the last year.    		Yes in the last year.

General Health Questions

Do you have any medical conditions? Please give details

Are you on any Prescription Medication? Please give details, also please note that you will need to see the Doctor for your first prescription from this Practice.

Do you have any Allergies? Please give details

Have you had any vaccinations in the past 10 year? Please give details
For children under 16 please provide a copy of their vaccinations.

Have you had any operations in Hospital? Please give details including the hospital where the procedure was done.

Physical Activity Questionnaire

Please tell us the type and amount of physical activity involving in your work.

		Please tick 1 box only	
a	I am not in employment		
b	I spend most of my time at work sitting		
c	I spend most of my time at work standing or walking, however my work does not require much intense physical activity		
d	My work involves definite physical effort, including handling of heavy objects and use of tools		
e	My work involve vigorous physical activity, including handling of very heavy objects		

During the last week, how many hours did you spend on the following activities?

	None	Less than 1 hour	1 hour but less than 3	3 hours or more	
a	Physical exercise such as swimming, jogging, gym workout etc.					
b	Cycling, including cycling to work and during leisure time					
c	Walking, including walking to work and during leisure time					
d	Housework/chidcare					
e	Gardening/DIY					

How would you describe your usual walking pace?  Circle one only

Slow Pace		Steady Average Pace		Brisk Pace		Fast Pace

If you suffer from any Breathing Problems, including Asthma and COPD please complete the questions below:

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

All of the time	  Most of the time	  Some of the time 	 A little of the time       None of the time  

2. During the past 4 weeks, how often have you had shortness of breath?

 More than once a day      Once a day       3 to 6 times a week       Once or twice a week           Not at all  

3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

 4 or more nights a week         2 or 3 nights a week         Once a week         Once or twice         Not at all  

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)?

 3 or more times per day    1 or 2 times per day    2 or 3 times per week    Once a week or less    Not at all  

5. How would you rate your asthma control during the past 4 weeks?

 Not controlled at all     Poorly controlled     Somewhat controlled    Well controlled    Completely controlled  

Thank you for completing this questionnaire. 

Please be aware that as part of the registration process you will need to book an appointment to see the Health Care Assistant before you can make an appointment to see the GP. 
As part of your routine health check with the HCA/Nurse, you will be required to provide a sample of urine on arrival.

(If you fail to attend 2 booked appointments with the Health Care Assistant, you will no longer be eligible to register and you will have to find an alternative practice)

Your named GP is Dr A Dasu