topsham surgery new patient questionnaire welcome to our practice to register with the practice please complete this questionnaire as

Topsham Surgery
New Patient Questionnaire
WELCOME TO OUR PRACTICE
To register with the Practice please complete this questionnaire as
fully as possible. The information will help the Doctor to make an
initial assessment of your health which will help in your future
treatment.
Title: ….…….. Surname: ………….……..………………….. Forename(s): …………………………………….
Date of Birth: ……………………………..………… Marital status: ….…………………………..………
Address: ……………………………………………………………………………………………………………………….
……………………………………………………………….… Postcode: …………………………………....….
Telephone Nos. Home: …………………… Work: ……………..…… Mobile: ………………………………
Topsham Surgery sends a text confirmation of appointments made and a
further text reminder 24 hours before your appointment. If we have
details of your mobile telephone number, these messages will be sent
to your mobile. The Surgery will not pass your personal information
onto any third party. By signing this form you are agreeing to the
Surgery contacting you in this way but if you do not wish to receive
these texts please let us know.
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Do you have any special communication requirements? If so please let
us know how you would like us to communicate with you and explain what
communication support would be helpful for you.
……………………………………………………………………………………………………………………….
Do you suffer from any major health problems i.e. asthma, diabetes,
blood pressure, heart disease, cancer, epilepsy, stroke, depression.
If yes please state:
………………………………………………………………………………………………………………………
Please give details of any medication you take (prescribed or
otherwise):
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Have you had any serious illness in the past?
………………………………………………………………………………………………………………………
Are you awaiting hospital treatment? If so what treatment and at what
hospital?
………………………………………………………………………………………………………………………
Are you allergic to any substances or foods? If yes please state:
………………………………………………………………………………………………………………………
Do you have any family members who have, or have had, a serious
illness i.e. asthma, diabetes, blood pressure, heart disease, cancer,
epilepsy, stroke, depression. If yes please state and if possible the
age they developed the condition.
Family Member Age Developed Condition Type of illness
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Smoking : Do you smoke? Yes / No How old were you when you started
smoking? ……………..
If Yes, how many: Cigarettes per day ………. Cigars per day ……...…..
Ounces of tobacco per day ……….
If you are a smoker, would you like help giving up? Yes/No
Ex-Smokers : How old were you when you stopped smoking? ………… What year
did you quit? ……………
How much did you smoke per day? …………………………………..
Alcohol (Please circle your answer)
How often do you have a drink that contains alcohol?
Never / Monthly or Less / 2-4 times per Month / 2-3 times per Week /
4+ times per week
How many standard alcoholic drinks do you have on a typical day when
are you drinking?
1-2 / 3-4 / 5-6 / 7-8 / 10+
How often do you have 6 or more standard drinks on one occasion?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you found you were not able to stop
drinking once you had started?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you failed to do what was expected of
you because of drinking?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you needed an alcoholic drink in the
morning to get you going?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you had a feeling of guilt or regret
after drinking?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you not been able to remember what
happened when drinking the night before?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Have you or someone else been injured as a result of your drinking?
No / Yes, but not in the last year / Yes, during the last year
Has a relative/friend/doctor/health worker been concerned about your
drinking or advised you to cut down?
No / Yes, but not in the last year / Yes, during the last year
Diet
Do you have a special diet? If so please state:
………………………………………………………………….
Do you add salt to your food after cooking? Yes / No
Do you have a varied diet including milk, meat, vegetables and fruit?
Yes / No
Has your Cholesterol been checked in the last 2 years? Yes / No
Exercise
Do you take regular exercise? Yes / No
If yes, what sort of exercise and how many times per week?
……………………………………………………
Height/Weight (17yrs and over only).
Height (approx): …………..………………………….. Weight: ……………………….…………………………
Female Patients
If applicable date and result of most recent cervical smear:
……………………………………………………..
If applicable date and result of last mammogram:
……………………………………………………………….
Carers
Do you need/have anyone who looks after you or your daily needs as
Carer? Yes / No
If “Yes”, would you like them to deal with your health affairs here?
Yes / No
If “Yes”, please give name, address and telephone number of your
Carer:
……………………………………………………………………………………………………………………….
Are you a carer for anyone else? Yes / No
If “Yes”, please give their name & your relationship to the person you
care for:
……………………………………………………………………………………………………………………….
Please ask about Carers’ support.
Next of Kin
Please give details of someone that we can contact in the case of an
emergency
Name ………………………………………………………….. Relation/Friend …………………………………
Address …………………………………………………………….. Tel No………………………………………
Ordering repeat prescriptions (PLEASE ALLOW 2 WORKING DAYS FOR YOUR
PRESCRIPTION TO BE PROCESSED).
For safety reasons and to avoid errors we are unable to accept repeat
prescription requests over the telephone. Please submit a repeat
prescription slip from your previous GP Surgery as proof of your
current medications. We can then add these to your medical record
ready for when you need to request them.
To order your prescription you can either: E-mail –
[email protected]
Fax – 01392 875261 (Topsham)
01392 873536 (Glasshouse Lane)
Post – Topsham Surgery, Holman Way, Exeter, EX3 0EN Glasshouse Lane
Surgery, Glasshouse Lane,
Countess Wear, Exeter, EX2 7BT (Including a S.A.E)
Register for our online registration and order your prescriptions
online.
Hand in at Reception or one of the Pharmacies listed below.
Your preferred Pharmacy: Topsham Pharmacy
(please select one) Glasshouse Pharmacy
Tesco Pharmacy, Exe Vale
Boots Pharmacy, Exeter High Street
NHS Organisations are required to collect details about ethnicity.
This information is collected to fulfil that obligation and is used
for monitoring purposes only.
I would describe my Ethnic Origin as follows :-
□ White British
□ White Irish
□ Other White Background
□ Bangladeshi
□ Indian
□ Pakistani
□ Other Asian Background
□ African
□ Caribbean
□ Other Black Background
□ Mixed White & Asian
□ Mixed White & Black African
□Mixed White & Black Caribbean
□ Other Mixed Background
□ Chinese
□Other Ethnic Group (please specify)
Please indicate your Religion or Belief :-
□ Atheism
□ Buddhism
□ Christianity
□ Islam
□ Jainism
□ Sikhism
□ Judaism
□ Hinduism
□ Other (please specify)
Please indicate your Language :-
□ Arabic
□ Bengali
□ Cantonese
□ English
□ Farsi
□ French
□ Gaelic
□ Gujarati
□ Hakka
□ Hindi
□ Korean
□ Mandarin
□ Patois/Creole
□ Polish
□ Portuguese
□ Punjab
□ Somali
□ Spanish
□ Tamil
□ Turkish
□ Urdu
□ Vietnamese
□ Welsh
□ British Sign Language
□ Any other language (please specify)
When returning your completed questionnaire to the Surgery, please
bring with you PHOTO ID and PROOF OF ADDRESS/UTILITY BILL. Thank you.
Office use only
Proof of residency /ID checked by……………………………………………… Date ………………….
□ Passport
□ Birth Certificate
□ Driving Licence
□ Proof of Address / Utility Bill
□ Work / Study Permit
□ Update Nominated Pharmacy
□ Donor Form Signed
BP check done? Attach printout here.
Signature of member of staff
Allocated GP (XacWQ)
Patient Informed of named GP (Xab9D)
Name of Previous GP & Surgery

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