new patient questionnaire jan 09

							                      orth Leeds
                                            Medical Practice
                                                                              Harrogate Road & Milan Street Surgeries




Harrogate Road Surgery                                                                               Milan Street Surgery
355 Harrogate Road                                                                                         2 Milan Street
Leeds LS17 6PZ                                                                                           Leeds LS8 5JW

Tel: 0113 2680066                                                                                      Tel: 0113 2490598
Fax: 0113 2953242                                                                                      Fax: 0113 2954029

PATIENT HEALTH QUESTIONNAIRE

Thank you for joining our surgery. It takes a few weeks for us to receive your medical notes from
your previous GP. In order to provide good clinical care we would be grateful if you could complete
the following questionnaire. Please only answer the questions you feel comfortable with.

Name…………………………………………………………….

Date of birth………………………                               AGE……..........................

Telephone number: Home…………..…Mobile………………..

Email address                               …………………………………

Next of kin: Name (Relationship) ……………………………….…
             Address/Phone: …………………………………
                                 …………………………………
Ethnic Group …………………………………………….

What is your main spoken language: ……………………………

Do you need an interpreter………………………………………

Do you look after someone who is ill, frail or disabled?    Yes/No
If yes, we will contact you with further information.
If you are a carer, do you receive help from Social Services or other
                            ……………………………………………

Are you: a current smoker                    an ex-smoker               Never smoked 
(Please tick)

Are you trying to stop? ………………………………………..
                                   If yes, we run a no smoking clinic. Would you
                                   like us to contact you with further information?
                                                                                      Y/N

Height ………………                      Weight …………..

Partners: Dr N Nazir, Dr M Purewal, Dr M Julier, Dr T Carroll, Dr K Hickman
Alcohol: Audit-C Questionaire(>5 indicates hazardous or harmful drinking)

Questions                                      0     1                    2           3           4        score
How often do you have a                        never Monthly              2-4 times   2-3 times   4+ times
drink that contains alcohol?                         or less              per month   per week    per week
How many standard alcoholic                    1-2   3-4                  5-6         7-8         10+
drinks do you have on a typical
day when you are drinking?
How often do you have 6 or                     never Less than monthly                weekly      Daily or
more standard drinks on                              monthly                                      almost
One occasion?                                                                                     daily

What is your weekly alcohol intake in units…………………
(e.g one pub measure of spirits, ½ pint of lager or beer, 125ml glass of wine)


Do you suffer from (please tick):

ASTHMA                 CHRONIC BRONCHITIS                              DIABETES          CANCER 

EPILEPSY                  HEART PROBLEMS                        THYROID PROBLEMS 

HIGH BLOOD PRESSURE                                  MENTAL HEALTH PROBLEMS 

If you have ticked any of these a member of staff will call you in due course to offer you an appointment at
one of our clinics.

ANY OTHER HEALTH PROBLEMS NOT LISTED ABOVE:

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………

HAVE YOU HAD A HEART ATTACK? 

PLEASE LIST ANY MEDICATION YOU ARE TAKING:
(or attach your repeat prescription slip from your previous dr)

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………

Do you have any allergies?………………………………………
                         ……………………………………….


THANK YOU FOR YOUR TIME

Should any details change in the future, please let reception staff know.
Partners: Dr N Nazir, Dr M Purewal, Dr M Julier, Dr T Carroll, Dr K Hickman