Medical Questionnaire Medical Questionnaire Personal DetailsNHS Number (Required) Prefix DrMissMrMrsMsProf.Rev. First name(Required) Surname(Required) Date of Birth(Required) DD slash MM slash YYYY Home Phone NumberMobile Phone Number(Required)Would you like us to contact you via SMS messages?(Required) Yes No Address(Required) Street Address Address Line 2 City Post Code Email Providing your email address indicates you are happy for the Practice to contact you via this methodAre you a student?(Required) Yes No Next of KinName(Required) Address(Required) Street Address Address Line 2 City Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Number(Required)Relationship to you(Required) Other InformationMain spoken language(Required) Do you require communication assistance?(Required) Large print British Sign Language Interpretor None If an interpreter is necessary, please inform us each time you book an appointmentAre you EX military?(Required) Yes No Please provide your service number:(Required) Health DetailsBlood Pressure Pulse Height Weight Waist Circumference Do you have any Allergies?(Required) Yes No List of allergies(Required)What are you allergic to?Details of reaction: Are you on any repeat medication?(Required) Yes No If you answered yes to the above question, you will need to make an appointment to see either a Pharmacist or a GP to obtain your next prescription. Family History(Required) Heart attack or angina before aged 60 Heart attack or angina over aged 60 High Blood Pressure Asthma Diabetes Stroke Cancer Any inherited disease None of the above Have any of your immediate relatives (brothers/sisters/parent) had any of the following? Please tick boxes and give details if possibleDetails & Relationship(Required)How would you describe your ethnicity?(Required) White British Irish Gypsy, Roma or Traveller Other White Asian British Bangladeshi Indian Pakistani Other Asian Black British African Caribbean Other Black Asian & White Asian & Black Asian & Caribbean White African White Caribbean Mixed Other Chinese Japanese Middle Eastern Turkish Other:(Required) Are you a smoker?(Required) Yes No Ex- smoker How many do you smoke a day?(Required) If you would you like support and/or information on giving up, please ask reception for an advice leaflet.When did you stop?(Required) Day Month Year Do you drink alcohol?(Required) Yes No How many units per week?(Required) How often do you have a drink containing alcohol?(Required) Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking?(Required) 1 -2 3 - 4 5 - 6 7 - 9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?(Required) Never Less than monthly Monthly Weekly Daily or almost daily CarersIf you care for or look after: Your husband or wife, child, parent, another member of the family or neighbour, because that person is unable because of illness, disability or old age to perform daily tasks themselves; and if the caring role occupies many hours a week or makes a significant change to your lifestyle, then you are a carer and we would like to support you. Are you a carer?(Required) Yes No Is someone a carer for you?(Required) Yes No Name, Address, Telephone Number, Care you provide? GP (if different to your own)(Required)Summary Care Records – OPT-OUTThe NHS in England has introduced the Summary Care Record, which will be used in emergency care. The record will only contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health. Queen Square Medical Practice is supporting Summary Care Records, but as a patient you have a choice. If you would like a Summary Care Record, then you do not need to do anything and a Summary Care Record will be created for you. If you do not want a Summary Care Record then sign the opt out below. For more information, please visit: www.nhscarerecords.nhs.uk, or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020 I do not want a Summary Care Record Name:(Required) Date:(Required) Sharing your Data for anything other than our Personal Care & The National Data Opt-out Patients’ personal confidential data is extracted and shared with NHS Digital in order to support vital health and care planning and research. Further information can be found by visiting the NHS Digital website: https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/general-practice-data-for-planning-and-research Patients may opt out of having their information shared for Planning or Research by applying a National Data Opt Out and/or a Type 1 Opt Out. For more information, please see our website or go to https://www.nhs.uk/your-nhs-data-matters/ Type 1 Opt-out (Opting out of NHS Digital collecting your data) Complete the type 1 opt-out form on our website: https://www.lancastermedicalpractice.co.uk/website/LMP001/files/Type-1-Opt-out-form.pdf and post to the surgery or email to us at [email protected] You can: • register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient) (to Opt-out) • withdraw an existing Type 1 Opt-out, for yourself or a dependent (if you are the parent or legal guardian of the patient) if you have changed your preference (Opt-in) National Data Opt-out (opting out of NHS Digital sharing your data with other organisations) You will need to either: 1. Go to the website: https://www.nhs.uk/your-nhs-data-matters/manage-your-choice/ It will be useful to have your NHS no and an up to date email address or mobile phone number in your GP record which will be used to identify you. 2. By Phone: Call the NHS Digital Contact Centre on 0300 303 5678, Available Monday to Friday between 9am and 5pm (excl Bank Holidays) 3. By Post: A form is available to download from https://assets.nhs.uk/prod/documents/Manage_your_choice_1.1.pdf which you can complete & return to them by Post. You can also make or change a choice for your children under the age of 13 or for someone you can legally make decisions for (You must have legal authority to make a choice for someone else, eg by Power of Attorney). These are both done by post, you can download the forms at https://www.nhs.uk/your-nhs-data-matters/manage-your-choice/other-ways-to-manage-your-choice/ but you will need to arrange to do this. The practice is not able to process your National data opt-out for you. Is there anything else you feel we should know about your health? (e.g. currently pregnant) Please be aware that due to a technical glitch our new patient registration process is taking longer than usual. If completing our online forms, you should expect your registration to be completed in around 4 weeks. If your registration is urgent, please give the practice a ring on one of our numbers. Please note that we are not currently notifying patients of the completion of their registration but we are working on a solution for this. Thank you.