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Health Questionnaire

Having up to date health details about our patients is vital in providing the best healthcare possible.

If you have received a health questionnaire in the post, or have been given one in the practice, you can fill this out here on the website and send it to us directly to save you filling it out on paper and sending it back to us.

If you have not received a health questionnaire from us, please do take the time to fill this in, it will help us immensely, thank you.

Your Name *


Your Telephone Number

Your Mobile Telephone Number


Your E-mail Address *

Basics

Your Date of Birth
(DD/MM/YY)


Weight (Stones / Kilos / Pounds)

Height (Feet / Inches / Centimetres)

Have you had your Blood Pressure Checked in the last 10 years?

Have you had a Tetanus Jab in the last 10 years?

Occupation


Do you take any form of exercise?

 

Lifestyle

Do you Smoke?

If you smoke, how much do you smoke per day?


If you smoke, what do you smoke?


Have you previously stopped smoking? If so, when?

If you are a smoker and would like to give up smoking, we have a smoking cessation clinic set up at our Health Centre, would you like more information on this?

How many units of alcohol do you drink on an average week? If you are unsure, please tell us the amount of pints, glasses / bottles etc.

 

History

Has anyone in your family under the age of 60 had...

 
- A Heart Attack / Heart Disease
 - Stroke
 - Blood Clot

 - Cancer

Do you have any Past Medical History that you think may be valuable to us? (Please describe)

 

Other

Do you have any known allergies? (please describe if applicable)

What is your Ethnic Group? (The Department of Health has asked us to record the ethnicity of patients).


Other:


Ethnic Information Refused

 

Any further comments

I accept the Terms & Conditions of Use *


 

Our new web site is now up and running
Patient Toolbox
 - Navigation
- Request Prescription
- Update Your Details
- Health Questionnaire
 

 

The Patient Toolbox allows you, the patient to interact with us here at the surgery, 24 hours a day, 7 days a week, 365 days a year.

 

 

 
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