New Patient Questionnaire – Adult Please provide detailed information about yourself to enable us to provide the best care for you. All information will be kept strictly confidential. Patient Information Title* MrMissMrsMsOther NHS Number If Known Name* First NameLast Name Date of Birth* /Day /MonthYearDate Previous Surname Gender* MaleFemaleOtherRather not say Place of Birth* Town & Country If not born in the UK please state date of arrival -Day -MonthYearDate Address* Street Address Street Address Line 2 CityCounty Postcode Home Tel* Work Tel* Mobile Tel* Email* example@example.com Previous GP* Address while at previous GP* Street Address Street Address Line 2 CityCounty Postcode Marital Status* SingleMarriedSeparatedCo-habitingWidowed Occupation* Religion* Your next of kin or who you would like us to contact in an emergency Name* First NameLast Name Relationship* Tel Number* To which ethnic group would you say you belong?* Are you allergic to any drugs?* YesNo Please specify* Are you allergic to anything else?* YesNo Please specify Nominated pharmacy for EPS What was the date of your last smear test? If applicable Where was it carried out? What was the result? What is your height?* What is your weight?* Have your ever smoked tobacco* YesNo Do you still smoke?* YesNo How many cigarettes per day did/do you smoke?* How often do you have a drink containing alcohol?* NeverMonthly or less2 - 4 times per month2 - 3 times per week4 + times per week How many units of alcohol do you drink on typical day when you are drinking?* 1-23-45-67-910+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?* NeverLess than monthlyMonthlyWeeklyDaily or almost daily About your family's health Has anyone in your immediate family (ie. parents, siblings or grandparents) suffered from any of the following ilnesses? Family Member Age of onsset Comments Diabetes High Blood Pressure Asthma Heart Disease Stroke High Cholesterol Mental Illness Cancer - specify type in comments Would you like to sign up for online services?* YesNo Signature Name* First NameLast Name Signature* Clear Date of birth* -Day -MonthYearDate SaveSubmit Should be Empty: