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Llysmeddygconwy.co.uk

LLYS MEDDYG SURGERY
23 Castle Street, Conwy, LL32 8AY
Drs Hindle, Britto and Evans and Dr Osborne (Associate)

Tel/Ffon: (01492) 592424
Fax/Ffacs:(01492) 593068
Email/Ebost:
Website/Gwefan:
NEW PATIENT HEALTH QUESTIONNAIRE
Thank you for registering with us at Llys Meddyg Surgery. We hope that
you will find us helpful and efficient in the service we offer you. As it
sometimes takes a while for GP records to be delivered from your
previous practice, we would like to offer you an appointment with one of
our practice nurses for a ‘new patient registration check’. This gives us
a chance to record your basic health background so that we have as
much information to help us care for you until your medical records
arrive. The information provided will assist also in the identification of
people needing long term management of their medical conditions, and
ensure that we can focus our care and advice on your health needs.
Your appointment is on (day)…………….(date)……….(time)………am/pm
It would greatly assist us if you could complete this questionnaire and
return it with your registration form or bring it with you for your
registration appointment.
Your full name:.
Date of Birth:………………………………………………………………………….
Status (circle as appropriate): Single/Married/Widowed/Divorced/Separated/
Co-habiting/Other (please state) ………………. Place of birth: ……………… Previous GP and surgery: ………………………… Occupation: …………………………………………………………………………. If schoolchild, name of school: ……………………………………………………. No and ages of children:……………………………………………………………. Or if the patient is a child, number and age of siblings Are you living in a childrens home, with foster parents or in a residential school named in your statement of Special Educational need or other accommodation arranged by a local authority or LHB? If Yes, please state which:………………………………………………………….
Next of Kin……………………………………………. Relationship…………….
Contact details of Next of Kin……………………………………………………….


MEDICATION
Are you on any regular medication? If so, please list below (or attach your
prescription reminder from your old practice)
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………………….
If you are on medication that requires regular blood tests i.e. warfarin,
Methotrexate
Please state:…………………… When was your last blood test: Date ………
Do you have any of the following, and if so when did you last have your
injection:
Zoladex Date:……………. B12 Date: ………… Depo Provera Date: ………
Do you have any medication or other al ergies? ………………………………….
PAST MEDICAL HISTORY
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
Have you ever had any serious illness? If so what and when?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
PAST SURGICAL HISTORY
Have you had any operations? If so, what and when?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
Have you had a Pneumonia Injection? Yes/No If yes, when? Date
approx:……….
SMOKING
Do you smoke? Yes/No/Ex.

WEIGHT AND HEIGHT

Approx Weight: ………………………. Approx Height: ………………………….
ALCOHOL
How many units of alcohol do you drink each week? …………………………….
(1unit = half pint of beer, 1 glass of wine, or a pub measure of spirits)
DIET
Do you have a diet that includes milk, meat, vegetables and fruit? Yes/No
If No, please state type of diet followed ……………………………………………
Do you add salt to your food after cooking? ………………………………………

EXERCISE
How many minutes for at a time?. How many times a week?.

FAMILY HISTORY

Is there any of the following in your family? (father, mother, brother, sister,
grandparent)

Which family
affected?
Heart disease (heart
attacks, angina, etc)
Diabetes?
High blood pressure?
Epilepsy?
Thyroid problems?
Respiratory problems
eg asthma/COPD?
Liver disease?

Kidney disease?

Mental Health Problems?
Any other significant
illness? What?

Are you concerned about your health in any way or is there anything in
particular you would like to discuss further with a member of the practice
team?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………………….
FEMALES ONLY
Have you had a smear test; if so when and what
was the result? Have you had a mammogram; if so, approximately when? Have you had a rubella injection (german measles)? Current method of contraception
Do you have a disability? Yes/No (If yes, please indicate with a tick below)
What is the nature of your disability?
Dyslexia……………………. Mobility (walking disabilites)………………………. Mental health difficulty……………………………… Blind/partial y sighted………………………………. Progressive disability/chronic disability (eg MS, Cancer) ………………. Dear/hearing loss ………………………………………. Learning Disability …………………………………. Multiple Disabilities………………………………… Other…………………………………………….
CARERS
Do you need/have anyone who looks after you or your daily needs as a
Carer? Yes/No
If ‘’Yes’’, would you like them to deal with your health affairs here? Yes/No
Do you care for anyone else? Yes/No
If ‘’Yes’ , ask at reception about initiatives for Carers support locally

Please indicate your ethnic origin. This is not compulsory, but may help
with your healthcare as some health problems are more common in specific
communities, and knowing your origins may help with the early identification
of some of these conditions.
Please tick the relevant box which best suits you:
White

Are there any other clinical requirements that may help us to provide the best
care for you?
Please state:
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
Thank you for taking time to complete this questionnaire. It will save
considerable time when you attend for your registration appointment.

Source: http://www.llysmeddygconwy.co.uk/website/W94016/files/New_patient_health_questionnaire_jan_2011.pdf

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