Forms

General Health Questionnaire

It is important to us that we stay in touch with our patients and continue to care for your health, even when you are fit and well! So if you haven’t had cause to visit the surgery in a while, please complete this General Health Questionnaire to ensure we are up-to-date for your next visit.

All fields marked * are required.

Full Name: *

Date of birth: *

Day: Month: Year:

Postcode:

Your Health

Height: *

Weight: *

Do you smoke? *

Yes No

If yes, how often do you smoke? (number per day)

Cigarettes:

Pipe:

Cigars:

Has your GP or nurse given you advice about smoking?

Yes No

If you do not smoke, have you ever smoked?

Yes No

If you would like help and support to stop smoking, the surgery is pleased to offer this service. Please make an appointment with the Practice Nurse.

Do you drink alcohol? *

Yes No

If yes, how much do you drink? (units per week)

Wine:

Beer or cider:

Spirits:

Other:

Is there anything regarding your health you would like to bring to our attention?

Thank you for taking the time to complete this form. We look forward to seeing you when you next visit the surgery.

For peace of mind, we offer all patients the choice of a Well Man Check, Well Woman Check or (for patients of 15 - 24 years of age) a Young Person Check. Please contact the surgery to book.

If you find it difficult to visit the surgery, please note that extended opening hours are available on Saturday mornings and Thursday evenings.

Please complete or update the online Contact Preferences Form if you have not already done so.