New Patient Health Questionnaire (Adult)

To make our website work efficiently and to provide our website visitors with a good experience when using the website, we use cookies. Cookies are small data files that are placed on your computer or mobile device when you visit a website. Consenting to cookies will allow us to process data such as browsing behaviour or unique IDs. We only share this data with organisations that provide services to the NHS. Not consenting or withdrawing consent to cookies may adversely affect certain features and functions of our website. Please also see the practice’s privacy policy as this may differ to the GPsurgery.net network privacy policy.

Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

New Patient Health Questionnaire (Adult)

Step 1 of 5

Your Contact Details

Information About You

Previous GP

Proof of Identity and Address Provided

Medical Information

Have you ever suffered from? (tick as appropriate)

Medical Information (continued)

Carers

Will

Women

Smoking

Alcohol

Family History

Next of Kin

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Contacting You

Signature

Date and signature

Further Info