Scribd
Upload
59 views

Pembroke Road Surgery: New Patient Questionnaire

This document is a new patient questionnaire for Pembroke Road Surgery. It requests basic contact information, medical history including smoking status and allergies, and demographic information about ethnic origin and language to help provide appropriate healthcare services. Patients are asked to have their blood pressure taken if not on regular medication.

Uploaded by

egcarreno
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
59 views

Pembroke Road Surgery: New Patient Questionnaire

This document is a new patient questionnaire for Pembroke Road Surgery. It requests basic contact information, medical history including smoking status and allergies, and demographic information about ethnic origin and language to help provide appropriate healthcare services. Patients are asked to have their blood pressure taken if not on regular medication.

Uploaded by

egcarreno
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Pembroke Road Surgery

New Patient Questionnaire


In order for you to be fully registered at the practice we require you to answer the following questions and have your blood pressure taken.

Name.Date of Birth... Home Phone Number Mobile/Work.... Email Address... National Health Service No.. Next of kin ......... Relationship Phone No Next of kin address... .. Have you been registered here before? Are you a smoker? (Please circle) YES YES NO NO Where did you hear about us? ...

If you answered yes to this question, what do you smoke? (e.g. cigarettes/pipe)... How many/much do you smoke per day?............................................................................................................................. Have you ever smoked? (Please circle) YES NO

If yes, when did you stop?.................................................................................................................................................... Are you on any regular medication? YES NO If you answered yes to this question please make an appointment to see one of the GPs. If you answered no to this question, we require you to have your blood pressure taken. Please ask at reception. Do you have any allergies? Drug: YES NO Non-drug: YES NO

Patient Profiling We aim to provide Health Services for all people, regardless of race or language. In order to do this, we need to know more about the population we are serving and are therefore asking you to answer 2 questions on this form. This will help us to provide the right type of healthcare services for all our patients. It will also help us provide the right number of language interpreters, for example. The personal information you give us on this form will not be shared with any other organisation, including other Government departments such as The Home Office or The Inland Revenue. If you have any concerns about the use of the data, please talk to a member of staff at the practice. What do you consider to be your ethnic origin? o I do not wish to complete this form Asian or Asian British o Bangladeshi o Indian o Pakistani o Asian other (please state) White o British o Irish o White other (please state) Mixed Background o White and Asian o White and Black African o White and Black Caribbean o Other mixed background (please state) Black or Black British o African o Somali o Caribbean o Black other (please state) Other Ethnic Group o Chinese o Any Other (please state) What language do you usually speak?................................................ What language do you usually read?...................................................

Thank you for your time.

For office use only:

IDx2

BP

Postcode

All info OK

Checked by

You might also like