Dr Kidd & Dr Cosgrove’s Practice
New Patient Health Questionnaire

Please complete the following questionnaire and bring it with you at your first appointment.  The information you provide will help us with your future medical care.

Personal Details

Name	………………………………Previous Surname…………….……

Address…………………………………………………………………….

D.O.B……………………………..	Marital Status…………………….

Telephone no……………………..	Previous GP………………………

Occupation………………………	Allergies…………………………..

Nationality………………………	Ethnic Origin……………………...

Medical History 

Please list any serious illness, operations or accidents that you may have had, with dates where possible:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any repeat medications you are taking:
_________________________________________________________________________________________________________________________________________________________________________________

Do you suffer from:(please tick)
Asthma (   ),	   Hypertension (   ),    Epilepsy (    ),    High cholesterol (   ),
Diabetes:  insulin dependent (   ),  or  non insulin dependent (   ).

Is there a family history of: (please tick)
Asthma (  ),  Heart Disease  (   ),  Diabetes (  ),  Hypertension (   ) 
Epilepsy (   ),  Stroke  (   ).
Female patients only

Have you ever had a cervical smear test?  Yes (   ),   No (    ),

If yes, approximate date _______________________________________

If known, what was the result of this smear?_______________________

Have you ever had a mammogram?  Yes (  ),  No (   )

If yes approximate date________________________________________

Do you use the oral contraceptive pill: Yes (   ),  No (   )

Life style

Do you smoke?  Yes (     ),  No  (    )

If yes, how many? ____________________________________________

If no, have you ever smoked and when did you stop? 

___________________________________________________________

Do you drink alcohol?  Yes (   ),  No (    )

If yes, how many units per week? (Pint = 2 units, small glass of wine = 1.5 units, measure of spirits = 1.5 units)

___________________________________________________________

Do you take exercise? Yes (    ),  No (     )

If yes, how many hours per week? _______________________________

Do you consider your diet healthy? Yes (   ),  No (   )