Patient Questionnaire | Awburn House Medical Practice

Title

Mrs

Miss

First Name(s)

Surname

Your Gender

Male

Female

Date of Birth

Email Address

Telephone

Mobile Number:

Preferred First Language:

Do You Have Children?

Yes

Ages:

Medical History

Height: (CM) or:

Height (FT) (Ins)

Weight (KGs) or (ST)

Weight (ST or Lbs)

Female Patients Only

Would you like family planning advice?

Yes

What type of contraceptive method do you use, if any?

Pill

Injection

Other

If other please specify:

Date of last cervical smear:

Have you ever had a mammogram?

Yes

If so, when:

Have you ever had a rubella vaccination?

Yes

If so, when:

Male And Female Patients

Have you ever been sterilised or had a vasectomy?

Yes

Date of last tetanus vaccination?

Do you take regular exercise?

Daily

Weekly

Do you take part in any sport?

Yes

If so, what?

All Patients

Are you a carer? (If yes, please ask for details how to register as a Carer)

Yes

If so, for whom do you care? (Name and Relationship)

Do you have a carer? (If yes, please give details of carer)

Yes

Details of carer?

Do you smoke?

Yes

If so how many per day?

Are you an ex smoker?

Yes

Would you like help or advice to stop?

Yes

Do you drink?

Yes

How many units per week?

Are you taking any medication at present?

Yes

If so what? (Please list medication dosage)

Are you allergic to anything?

Yes

If so, what?

Do you or any of your family suffer from any of the following?

High Blood Pressure:

Yes

If so, who?

Low Blood Pressure:

Yes

If so, who?

Heart Attack:

Yes

If so, who?

Glaucoma:

Yes

If so, who?

Epilepsy:

Yes

If so, who?

Diabetes:

Yes

If so, who?

Asthma

Yes

If so, who?

Angina

Yes

If so, who?

Stroke:

Yes

If so, who?

Eczema:

Yes

If so, who?

Cancer:

Yes

If so, who?

Hysterectomy:

Yes

If so, who?

Any Other:

Yes

If so, who?

Any other information you would like your GP to be aware of:

PLEASE ENSURE YOU HAVE COMPLETED A GMS1 FORM (ASK AT
RECEPTION) FOR YOURSELF AND ANY OTHER MEMBERS OF YOUR
FAMILY WHO ARE REGISTERING AT THE PRACTICE

THANK YOU FOR YOUR CO-OPERATION IN COMPLETING THIS FORM

IDENTIFICATION OBTAINED YES/NO
PLEASE STATE WHICH IDENTIFICATION:
(eg. Passport, utility bill)