Creich Surgery  
                                                                            
NEW PATIENT QUESTIONNAIRE

It would be most helpful if you could complete this questionnaire before you see the doctor. It asks for information relevant to your healthcare, which is confidential and will be kept in your personal file.

Today’s Date:   	

Title                                                .: 

Name: 
	Date of Birth    :                                        . 

Telephone
 number:    	

PAST MEDICAL HISTORY   
Please list any illnesses, operations or hospital admissions with dates

	

MEDICATION
Please list any prescribed medicines you are taking
Name                                              Strength               How often taken   

Please list any non-prescription medications you take regularly

ALLERGIES

Please list any medications you are allergic to or you have been told you must not take

LIFESTYLE FACTORS
	
Do you have any children?     Name                                 Age  

         
	
OCCUPATION (if retired, former occupation)

	
SMOKING  

If you smoke, how much do you smoke per day?                         .	
ALCOHOL

How much alcohol do you drink?                                         .… units per week.
A unit is a small glass of wine, a half pint of beer/lager or a measure of spirits.	

WOMEN ONLY
Are you using any method of contraception at present?                                        .
Age 20-65 yrs: when did you last have a cervical smear?                                     .
Have you had a hysterectomy?                                     .

FAMILY HISTORY
Has anyone in your family had the following?

•	High blood pressure                               ..
•	Heart disease/angina/heart attack                                 ..
•	Stroke                                  .
•	Diabetes                              ..
•	Thrombosis/blood clot                                       .
•	Cancer                                .
	CLINICIAN TO COMPLETE

Father

Mother

Brothers

Sisters