New Patient Questionnaire

The following questions will help us to know you and your medical history. It helps us look after you until your medical records arrive from your previous GP. Please answer as much information as you can.

Last Updated: 06/03/2025

Your Contact Details

Title (optional)

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Previous Surname (optional)

Address

Postcode

Home Number (optional)

Mobile Number

Email Address
Information About You

What is your height?

What is your weight?

What is your first language?

Do you need an interpreter?

Yes

No

Ethnic Group

White British

White Irish

White Other

Black British

Black Caribbean

Black African

Black Other

Asian Indian

Asian Pakistani

Asian Chinese

Asian Other

White & Black British

White & Black Caribbean

White & Black African

White & Asian

Other

Please enter details here
Medical Information

Please list any serious illnesses / operations / disabilities (optional)

Have you ever suffered from? (tick as appropriate) (optional)

Epilepsy

Blindness/Glaucoma

High Blood Pressure

Diabetes

Heart Attack/Stroke

Depression

Cancer

Asthma

Eczema/Hay Fever

COPD

If yes, please state the year(s) when were you first diagnosed? (optional)

Please list any medicines being taken and the amount: (optional)

Are you registered disabled?

Yes

No

If yes, please give details (optional)

Are you allergic to any medicines/or have any other allergies?

Yes

No

If so, which? (optional)

Have you ever suffered from? (tick as appropriate) (optional)

Anxiety

OCD

Depression

Bipolar Disorder

If yes to any of these, please state the year(s) when were you first diagnosed? (optional)
Carers

Do you have a carer?

Yes

No

If yes please give details (optional)

Are you a carer?

Yes

No

(If yes please give details) (optional)
Women

Have you ever had a cervical smear?

Yes

No

If 'yes', please state when, where and the result (optional)
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?

Would you like advice on giving up smoking?

Yes

No
Alcohol

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?
Family History

Some diseases run in families and it would be helpful if you could inform us of any diseases that any close relatives may have, please tick any that may apply to your family.

Diabetes

High Blood pressure

Heart disease

Stroke

Asthma

Any other disease,
Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Yes

No
Signature

Signature

Date
For example, 15 3 1984

Day

Month

Year

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Antonine Medical Practice website

New Patient Questionnaire

Your Contact Details

Information About You

Medical Information

Carers

Women

Smoking

Alcohol

Family History

Contacting You

Signature