Patient Questionnaire Please complete this questionnaire fully if you wish to register with our surgery.Name Forenames Surname Maiden Name Optional (If applicable)Date of Birth DD slash MM slash YYYY Present Address Street Address Address Line 2 Postcode Mobile Tel NoHome Tel No OptionalWork Tel No OptionalNext of Kin Relation Next of Kin's NumberEthnic OriginSelect…White ScottishWhite EnglishWhite WelshWhite IrishOther White Ethnic GroupIndianPakistaniBangladeshiChineseOther Asian Ethnic GroupBlack CaribbeanBlack AfricanOther Black Ethnic GroupMixed Ethnic GroupDo you need an interpreter or sign language support? Yes No (Please tick)If you do need an interpreter, what language do you speak? Optional (Please state)Please answer the following questions (Please tick or state)Marital Status Single Married Widowed Divorced Employment Status Unemployed Retired Housewife Full-time employment Part-time employment Nature of employment Previous Address Street Address Address Line 2 Postcode Previous Doctor Are you a carer for someone else? Yes No Are you on any drug treatment? Yes No (including contraceptive pill)If yes, please give name and dosage Optional(If possible)Do you take any other medication without a Doctor’s supervision? Yes No If yes, please give details Optional(eg: Aspirin/ Vitamins/ Homeopathic Remedies)Do you smoke? Yes No If yes, please tick the type Cigarettes Optional Roll-ups Optional Pipe Optional How Many Cigarettes per day /ounces per week Optional Would you like assistance to stop smoking? Yes Optional No Optional Do you drink alcohol? Yes No If yes, please tick type Beer Optional Wine Optional Spirits Optional Various Optional Please state number of glasses of wine / half pints per week: Optional Do you have any Allergies? Yes No (eg: Pencillin / Iodine / Pollens / General Anaesthetics, ect)If yes, please state OptionalPast Medical History (Please tick or state)Have you had any of the following chronic illnesses? Epilepsy Optional Stroke Optional Mental health problems Optional Heart disease Optional High BP Optional Asthma Optional Thyroid problems Optional Diabetes Optional Chronic lung disease Optional Eczema / psoriasis Optional Liver disease Optional Rheumatoid Arthritis Optional Have you suffered from Cancer in the last 5 years? Yes No Please could you give details of any operation or spells in hospital which have occurred in the past Optional(Please include dates where possible)Family HistoryIs there any tendency to high blood pressure, diabetes, heart attack, asthma, cancer or any inherited disease in the family? Yes No Please state any history of the above OptionalHealth ChecksWhen was your last…Blood pressure check? Optional Tetanus injection? Optional Advice on diet? Optional Urine test? Optional Cervical smear? Optional Breast examination? Optional Thank you very much for completing this questionnaire. Please return to the receptionist.