THE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+

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1 THE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+ Surname: First Name: Date of Birth: NHS Number: / / Mobile Telephone No: Male / Female If you wish to sign up for Vision On-Line services please enter your address clearly: Next of Kin: Telephone No: Do you speak English? Yes / No First language spoken: Are you an Asylum seeker? Yes / No Are you a Refugee? Yes / No Are you a carer? (not as an occupation) Yes / No If yes please complete a carer s form on page 5. Ethnic Origin: Please tick as appropriate: White Mixed Asian or Asian British British / Mixed British White & Black Carribean Indian Irish White & Black African Pakistani Other: White & Asian Bangladeshi Other European origin (please Other: Other Asian background: State): Black or Black British Chinese or other Ethnic Group Carribean Chinese African Other: Other black background (please State): Personal Medical History: Please specify any other major illness or operations, with dates: Have you suffered from: Date diagnosed Heart Disease / Heart Attack Strokes High blood pressure Diabetes Asthma Eczema / Hayfever Epilepsy Blindness / Glaucoma Cancer Depression / Mental illness 1

2 Drugs and Medicines: Please specify all drugs, medicines, tablets or pills that you take regularly including contraceptive medication. Please use attached sheet if you require more room. Allergies: Do you have any known allergies? Yes / No Date allergy diagnosed: If yes, please specify allergy: What reaction do you have: Family Medical History: Please specify age and relationship. Immediate family only. None: Heart Attack Stroke: High Blood Pressure: Diabetes: Cancer: Mental Illness: Asthma: Women only: Please be as accurate as possible Have you had a cervical smear test in the last 3 years: Yes / No Date Result Have you had a Hysterectomy: Yes / No Date: Why Are you pregnant: Yes / No If yes how many weeks? Would you like to join the Patient Participation Group? Yes No 2

3 Smoking History: Never smoked Ex-smoker Current smoker Date stopped Are you interested in stopping smoking: Yes / No If you are interested in quitting smoking please speak to a receptionist who will be able to book an appointment in our Smoking Cessation clinic. Smoking leaflet given to patient (Receptionist to tick) Diet and Exercise: Do you take regular exercise: Yes / No Gentle Moderate Vigorous I eat a good diet I eat a moderate diet I eat a poor diet I am a Vegetarian I am a Vegan Alcohol Questionnaire: Please complete by ticking the relevant answer. I have never drunk alcohol I am an ex-drinker I drink alcohol Q1 How often do you have a drink that contains alcohol? Never 0 point Monthly or less 1 point Two to four times a month 2 points Two to three times per week 3 points Four or more times per week 4 points Q2 How many standard alcoholic drinks do you have on a typical day when you are drinking? 1 or 2 0 point 3 or 4 1 point 5 or 6 2 points 7 to 9 3 points 10 or more 4 points Q3 How often do you have 6 or more standard drinks on one occasion? Never 0 point If total score is 5 or higher please complete more detailed questionnaire overleaf. If score is 8+ please give alcohol advice leaflet Total Score: 3

4 Alcohol Questionnaire continued. Q4 How often in the last year have you found you were not able to stop drinking once you had started? Q5 How often in the last year have you failed to do what was expected of you because of drinking? Q6 How often in the last year have you needed an alcoholic drink in the morning to get you going? Q7 How often in the last year have you had a feeling of guilt or regret after drinking? Q8 How often in the last year have you not been able to remember what happened when drinking the night before? Q9 How often in the last year have you or someone else been injured as a result of your drinking? No 0 points Yes, but not in the last year 2 points Yes, during the last year 4 points Q10Has a friend / relative / doctor / health worker been concerned about your drinking or advised you to cut down? No 0 points Yes, but not in the last year 2 points Yes, during the last year 4 points Total Score: Score 8+ Please book a 20 minute appointment with nurse and give Alcohol advice leaflet, GAD-7 and PHQ forms. Alcohol advice leaflet given to patient (Reception only) 4

5 Form checked and accepted by: Print name: Date: Carer Questionnaire: If you give your consent for the following information to be entered on your medical records please complete. Cared for patient s name and address: Telephone number: Do you need any assistance with your caring duties? Yes / No If yes please specify Would you like to discuss your role as a carer with a clinician? Yes / No HCA new patient registration check Height: Weight: BP: Urine: 5

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