New patient health questionnaire

Smoking
Do you smoke?
- Yes
- No
If 'No', have you ever smoked?
- Yes
- No
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?
Would you like advice on giving up smoking?
- Yes
- No
Alcohol
1 drink = 1/2 pint of beer OR 1 glass of wine OR 1 single spirit
MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
How often during the last year have you failed to do what was normally expected of you because of drinking?
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Family History
Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.
Next of Kin
Please give name, address, telephone number and relationship of next of kin.
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Have you had a flu vaccination? If yes, please specify the date.
Have you had a pneumococcal vaccination? If yes, please specify the date.
Contacting You
- I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.
Signature
Date and signature
(you will be asked to sign this form when you visit the practice)
Consent*
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.
I agree to the privacy policy.

Your Contact Details