Parkshot Medical Health Questionnaire for Newly Registered Adult Patients
Parkshot Medical may contact me about all aspects of my health and care using electronic messaging
Information regarding the Summary Care Record
Do you have any children?
Are you a Carer?
Does someone look after you?
Do you require information about your benefits for Carers?
Please indicate your ethnicity:
Please state which member of your family have any of the following conditions i.e. Mother, Father etc.
Diet
Smoking habits?
Please complete the following Audit C test:
Unit definition: 1 Glass of Wine = 1.5 Units, 1 Bottle = 10 Units, 1 Pint of Beer = 3 Units, 1 Spirit Measure = 1 Unit
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when drinking?
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?
Exercise Status
Sexual Health Lifestyle
Female Patients only:
Are you taking any contraceptive medications?
If yes, please state which one(s):
If your last cervical smear was performed outside the United Kingdom or if the procedure was carried out privately we will require documentation confirming this. Please bring this with you when you first attend the Surgery.
Was your last cervical smear performed:
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