New Patient over 16yrs Questionnaire

By providing your email address and mobile number you consent to the practice contacting you by these methods of communication for direct patient care, including national screening programmes. Please bear this in mind if you share an email account. We will send your log-in details for online-services by email, please check your junk folder if you do not receive them within 7 days.

Last Updated: 30/04/2021

Your Contact Details

Title

Name *

Date of Birth ie 01/01/1990 *

Home Number

Mobile Number *

Email Address *

Information About You

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? A carer is anyone, including children and adults who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. If 'yes' we will send you a form to fill out and return to the practice to add you to the carer's register and for this information to be recorded on your medical records. *

Yes No

Females Only

Will

Do you hold a Living Will? *

Yes No

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? If you would like help and advice to stop smoking, please call Healthy Cornwall on 01209 615600 to arrange an appointment with an stop smoking adviser

Alcohol

How many units of alcohol do you drink per week? As a guide a single shot of spirits is 1 unit, a pint of lower-strength lager/beer/cider (ABV 3.6%) is 2 units and a standard glass of red/white/rosé wine is 2.1 units *

1-14

15-21

22-28

29-35

36-42

43 or more

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you not been able to remember what happened when drinking the night before? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or 'never':

Have you had a pneumococcal vaccination? Enter date or 'never'

Summary Care Records

A Summary Care record is an electronic record that can help give you safer, faster care by giving healthcare staff instant access to information about your MEDICINES, ALLERGIES and MEDICINES which make you ill.

I would like to share my summary care record: *

Yes No

Signature: *

Enhanced Data Sharing Model

SystmOne is the clinical computer system used by Penryn Surgery. Opting into this method of sharing your medical information will allow other services who use this same clinical computer system, eg District Nurses, to access your medical record but ONLY if they have need to do so for your clinical care.

Do you consent to the sharing of data recorded here with any other organisation that may care for you? *

Yes No

Do you consent to the viewing of data by this organisation that is recorded at other care services that may care for you and where you have agreed to make the data shareable? *

Yes No

National Data opt-out

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. In May 2018 strict rules about how this data can and cannot be used were strengthened. You can choose whether your confidential patient information is used for research and planning. To find out more visit nhs.uk/your-nhs-data-matters Leaflets on all the above data sharing models can be obtained from reception.

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New Patient over 16yrs Questionnaire

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