1 Ashfield Road
NEW PATIENT MEDICAL QUESTIONNAIRE	Milngavie  G62 6BT
	0141 956 1339
	
Please complete the form and return to the surgery with your registration forms.

1.0 Personal Details	
Surname:	First Names:	
Date of Birth:	NHS number:	

Address:

Post code:

Contact Details:

Tel Home	

Tel Mobile	

E-mail	

	
Occupation:
	Occupation of Partner:
	No of dependents:
	
Ethnicity:	Marital Status:	

Previous Doctor Details:

Name

Address

	

Next of kin details:

Name		

Contact Tel no.

Relationship to you

	
Do you live with your family at the above address?	Yes / No
	
Do you live with other people to whom you are not related?	Yes / No
	
Do you look after any relatives not living with you?	Yes / No
	
Have you ever lived abroad?	Yes / No

2.0 Medical History	
2.1 Personal History

Have you ever suffered from any of the following conditions?  	(Please tick as appropriate)

Condition	
Date of diagnosis	
	
Condition	
Date of diagnosis	

Asthma 	(  )	

Mental Health Problems	(  )	

Diabetes 	(  )	

Cancer	(  )	

Epilepsy 	(  )	

Blindness/ Glaucoma	(  )	

Stroke 	(  )	

High Blood Pressure	(  ) 	

Heart Attack/Angina	(  )	

Raised Cholesterol	(  )	

Thyroid Problems 	(  )	

Other:	(  )	

Please list operations, serious illness or disabilities:

Operation	
Date	
	
Illness	
Date	
	
Disability	
Date	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

2.2 Family History

Has any close relative (parent, brother or sister) suffered from:  (Please tick as appropriate)

Condition	
	
Condition	

Heart Attack (Under 60) 	(  )
Stroke	(  )
Diabetes	(  )
Asthma	(  )		
	
High Blood Pressure  		(  ) 
Raised Cholesterol		(  )
Other		(  )

	
2.3 Medication and Allergies

Are you currently taking any tablets, medicines or injections?

Name	
Dosage	
Frequency	

	

	

	

	

	

	

	

	

Do you have any known allergies to medicines or foods?		Yes / No 

If 'Yes', please give details

2.0 cont’d	
2.4 Immunisations and Vaccinations
	
Children under 5 years
Vaccination	
Date	

2 months: 1st Diphtheria/Tetanus/Polio/Meningitis/Whooping Cough	

3 months: 2nd Diphtheria/Tetanus/Polio/Meningitis/Whooping Cough	

4 months: 3rd Diphtheria/Tetanus/Polio/Meningitis/Whooping Cough	

12 months: HIB/MenC	

13-48 months: Meningitis (HIB) catch up (Booster)	

13 months: Measles, Mumps, Rubella (MMR)	

4 years: Pre School Booster (Dip/Tet/Pert/Polio)	

4 years: MMR Booster	

Pneumococcal (PCV)	

Adults
Vaccination	
Date	

Tetanus Course/booster in Last 10 years?	

Polio booster in last 10 years?	

Annual Flu vaccination?	

Pneumococcal vaccination?	

Other?  Eg. Typhoid/Yellow Fever	

	
3.0 Lifestyle	

Please tick the appropriate answer

Smoking - What is your current smoking status?

Current smoker	(  )

Number per day  ..........  

Do you wish to stop smoking?

Ex smoker	(  )	

When did you stop smoking?

	

(  ) Never smoked

 
Drinking - How many units of alcohol do you drink eack week?  

1 unit = ½ pint beer = 1 spirit = 1 glass of wine

No of units ...........

Non Drinker	(  )

Diet - How would you describe your diet?

My diet is varied and balanced	Yes / No	

(   ) I am on a weight reducing diet	

I am on a special diet for medical reasons.	(   )
Reason ........................... 	

(   ) I am a Vegetarian / Vegan	

Exercise - How would you describe your current level of exercise?

(   ) None	
(   ) Impossible	
(   ) Light	

(   ) Moderate	
(   ) Strenuous	
(   ) Athlete	

	

4.0 Female Patient Only	
4.1 Cervical Smear

Please tick or complete / delete appropriate sections

Have you ever has a smear?	

Yes / No	

When did you last have a smear?	

Was the result normal?

If abnormal, please give details:

	

Yes / No	

	
4.2 Contraception

I currently / have previously taken contraceptive pills	

I started taking them in  ................................

Yes / No 

I currently have/ have previously had/ a coil

This was fitted/ removed in  ........................................

Yes / No	

	
4.3 Pregnancies

I have had  …… pregnancies, resulting in:

Live births  ……

Still births  …….

Miscarriages …..	
Have you had any problems during pregnancy?
Yes/No

If ‘Yes’, please give details:	

4.4 Other

Have you ever had a hysterectomy?	Yes / No	If ‘Yes”, date:  …………………………………

Have you ever had a mammogram?	Yes / No	If ‘Yes”, most recent date:  …………………….
		 
If 'Yes', please give details

THANK YOU FOR COMPLETING THIS FORM