Mexborough Health Centre
NEW PATIENT HEALTH QUESTIONNAIRE 
Thank you for taking the time to complete this medical questionnaire. The information you supply will help improve our service to you.
PATIENT DETAILS
Title	Mr		Mrs		Miss		Ms		Surname		
Date of Birth		First Names		
Occupation		Previous Surnames		
Address

Tel No:				Mobile:	Work No:	
Next of Kin Details: 

Name

Address

Telephone number

Relationship to patient	

The practice requires consent to send clinical information by SMS along with sending short messages by Text messaging         Yes   I give consent                           No I do not wish to give consent 
Online access to book appointments and request prescriptions   Yes                            No       
OTHER INFORMATION
Do you have a carer?		Yes		No 
Are you a carer?		Yes		No
If yes please give details: ………………………………………………………………………………………….

Do You Hold a Living will?		Yes		No 
Are you registered disabled		Yes		No
Example: Blind, Deaf, Learning disability, Severe Mental Health, Physical disability
Do you use a wheelchair		Yes		Sometimes	Always		No
Are you:                                                    Employed         Retired              Unemployed         

What could we do to make it easier for you to use our health services? (This could include accessible information i.e. messages by recording, braille letters etc.)

MEDICATION: Please ensure you have at least 2 months supply of medication from your previous GP. List any medications being taken and the dosages and provide a copy of your repeat request from your previous doctors. If you do not provide a copy of the counterfoil for medication his will cause delay for prescriptions to be continued.

	

Are you taking controlled drugs regularly (strong painkillers or patches)?  Yes / No
Were you signing to collect prescriptions from your previous surgery?
Yes /No
Please be aware we will do medication reviews regularly and we may decide for you to collect your prescriptions weekly/2 weekly/monthly.

MEDICAL INFORMATION illness / operations / fractures - Do you suffer from? OR Family history (FH)
Epilepsy                              Yes      No       FH	Blindness/Glaucoma          Yes       No       FH	
High Blood Pressure           Yes      No      FH	Asthma                               Yes       No       FH	
Heart Attack/Stroke             Yes      No      FH	COPD                                 Yes       No       FH	
Cancer                                Yes      No      FH	Depression                         Yes       No       FH	
Eczema/Hay Fever             Yes      No      FH	Diabetes                             Yes       No       FH	
Are you allergic to any medicines      No     or    Yes – please list

	
SMOKING							
Do you smoke?               Yes          No
If yes how many
Would You like advice on giving up smoking?       Yes       No	
Are You an ex-smoker     Yes         No
	
ALCOHOL
How much alcohol do you drink in a week?
	Units	
(1 unit = ½ pint beer, 1 small glass of wine, 1 single spirit, 1 small glass of sherry or 1 single aperitif)
	
OVER 16’s ONLY
Alcohol Users Disorders Identification Test (AUDIT) C
Questions	Scoring System	Your Score	
	0	1	2	3	4		
How often do you have a drink that contains alcohol?
	Never	Monthly or less	2-3 times per month	2-3 times per week	4+ 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		

Your height:				Your weight:				

Women Only
Do you have cervical smears?
Ring pessary – if YES when is it due to be changed
Contraceptive Pill – If YES when is your pill check due
Implanon – if YES when is it due to be removed / changed?
Coil – if YES when is it due to be removed / changed?
Please note we offer: Family Planning services (coil and implanon) also ring pessary fit and change for ladies with bladder problems. Minor surgery (removal of lumps bumps moles etc) and cryo therapy for warts.

Language
	What is your first language?		

Ethnic Group
	
White	British	
		Irish	
		Other (Please specify)		

Black	Caribbean	
		African	
		Other (Please specify)		

Asian	Indian	
		Pakistani	
		Chinese	
		Other (Please specify)		

Mixed	White & Black Caribbean	
		White & Black African	
		White & Asian	
		Other (Please specify)		

PROOF OF IDENTITY
Birth Certificate	Driving Licence	Passport	Utility bill
Allowance Book	Solicitor’s Letter	Offer of Tenancy
Other

Signature:
		
Date:		

 Information for new patients: about your Summary Care Record 
Dear patient, 
If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. 
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. 
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you. 
You have a choice 
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. 
Your options are outlined below; please indicate your choice on the form overleaf. 
 Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only. 

 Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you. 

 Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care. 

If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions. 
Once you have completed the consent form, please return it to your GP practice. 
You are free to change your decision at any time by informing your GP practice. 

Signature: ……………………………. Date: ……………………………… 

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details below: 

Name: …………......................................................................................................... 

Please circle one:                 	

Parent                   Legal Guardian           Lasting Power of Attorney for Health & Welfare

 Zero Tolerance – Abusive or Aggressive Behaviour
Our staff come to work to care for others, and it is important for all members of the public and our staff to be treated with courtesy and respect. 
In line with the rest of the NHS and to ensure this is fully observed, we have a Dignity at Work and Zero Tolerance policy.  This means that aggressive or violent behaviour towards our staff or any member of the public within our Practice premises will not be tolerated under any circumstances.
Anyone giving verbal abuse to members of staff, either in person or over the telephone, will be sent a letter from the Practice Manager advising that this behaviour will not be tolerated.  Any future violation of this policy will result in the removal from the Practice patient list.  There will be no appeal process.
We feel sure that you will understand that proper behaviour is absolutely necessary for our staff and patients and that non-observance will not be accepted.
Have you been registered at the practice before?   Yes  		No                
If yes why did you leave the practice?
What date did you leave the practice?         
Do you have history of threatening or violent behaviour?       Yes            No 
If Yes please comment	

Have you been identified by the Zero tolerance (violent behaviour initiative)?   Yes       No
If Yes please comment	

Office Use only:
Checked all information completed 
Signature 
Date