• New Patient Health Questionnaire for Adults

    New Patient Health Questionnaire for Adults
    Your contact details
    Title:
    DD slash MM slash YYYY
    Information about you
    Do you need an interpreter?(Required)
    Previous GP
    Proof of Identity and Address Provided
    Medical Information
    Have you ever suffered from? (tick as appropriate)
    Epilepsy
    Heart Attack/Stroke
    High Blood Pressure
    Cancer
    Eczema/Hay Fever
    Blindness/Glaucoma
    Diabetes
    Depression
    Asthma
    COPD
    Are you registered disabled?
    Have you ever refused treatment/screening of any kind?
    Are you allergic to any medicines?
    Have you ever suffered from? (tick as appropriate)
    Anxiety
    Depression
    OCD
    Bipolar Disorder
    Carers
    Do you have a carer?
    Are you a carer?
    Wills
    Do you hold a Living Will?
    (A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
    Women
    Have you ever had a cervical smear?
    Smoking
    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking?
    Alcohol
    1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
    Family History
    Next of Kin
    Contacting you
    For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
    Untitled(Required)