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The Garden City Surgery, Letchworth

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Appointments
Contact Us
eConsult Service
Join Our Surgery
Opening Hours
Prescriptions
Update Records

Home
About Us
Online Services
Our Staff

New Patient Health Check Questionnaire (ADULT)

This form is for patients who are sixteen years old and over.

Please only complete this form if you have been asked to.

Last Updated: 18/10/2024

Your Contact Details

Surname *

First Names *

Date of Birth *

Home Telephone *

Mobile Telephone *

Email Address *

Preferred Contact Method *

Letter

Email

SMS

Do you have any information or communication needs? *

Yes No

If you selected yes, how can we meet your needs

Consent to use mobile number for text alerts? *

Yes No

Marital Status

Single

Married

Divorced

Widowed

Occupation

What is your Nominated Pharmacy (Name and Address) *

Information about you

What is your first language? *

Do you need an interpreter? *

Yes No

Height

Weight

Medical History

We require full access to your records and also permission to share your records with other health care providers under the NHS umbrella to be able to provide you with our services.

Do you have any current medical problems? *

Yes No

If yes, please state what it is and the year(s) when you were first diagnosed?

Are you taking any medication? *

Yes No

If yes, please provide a copy of your repeat list.

Do you have any allergies? *

Yes No

If yes, please state what you are allergic to *

Do you have any mental health issues? *

Yes No

If yes, please state what mental health issue you have, and what year(s) you were first diagnosed

Are you receiving or have you received any treatment or therapy? *

Yes No

If yes, please give details of your care and when you received it

Family History

Has anyone in your family been diagnosed with one of the following?

Heart Attack

Stroke

Diabetes

Mental Illness

High Blood Pressure

Asthma

Eczema

Cancer

Epilepsy/Fits

If you clicked any of the above, please state the relation you have with this person, and when they were diagnosed. (If they've had cancer, please state what type.)

Next Of Kin

Your next of Kin's name *

Their Relationship To You

Their Address

Their Contact Number *

Carer Information

Are you a carer? Do you look after someone who relies on you for support? *

Yes No

Who do you care for?

Do you have a carer? *

Yes No

Carer's name

Carer's Address

Carer's Contact Number

Smoking

Have you ever smoked? *

Yes No

Do you still smoke?

Yes No

If yes, how many do you smoke per day?

If no, when did you give up?

Would you like help to stop?

Yes No

Alcohol

Remember:

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirit

How often do you have a drink containing Alcohol? *

Never

Monthly or Less

2-4 times a month

2-3 times a week

4 or more times a week

How many units of alcohol do you drink on a typical day when you are drinking? *

0-2

3-4

5-6

7-9

10 or more

MEN: How often do you have 8 or more drinks on one occasion. WOMEN: How often do you have 6 or more drinks on one occasion? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Exercise

Do you take regular exercise? *

Yes No

If yes, what sort of exercise?

How many times per week?

SIGNATURE

SIGNED *

DATE *

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