New Patient Questionnaire
  1. Welcome to Ashley Surgery. In addition to the GMS1 form, please complete this questionnaire. The information will be handled confidentially but if you are concerned about any of the questions, leave them blank. The information you provide now will be transferred to a form for you to sign when you attend the surgery.

  2. Your Full Name
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  3. Your Date of Birth
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        DD/MM/YYYY

  4. Your Email
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  5. In an emergency who should we contact on your behalf?                                                                                   

  6. Full Name
    Please type your full name.

  7. Address
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  8. Telephone Number
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  9. Relationship to you
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  10. Are you caring for someone or does someone care for you?
    A carer is a person who is looking after or is responsible for the care of a relative, friend or neighbour who is mentally or physically disabled or whose health is impaired by old age.

  11. Do you have a carer?
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  12. If you have selected Yes, please give details about your carer:                                                            

  13. Full Name
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  14. Address
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  15. Telephone Number
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  16. Relationship to you
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  17. Do you care for someone else?
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  18. If you have selected Yes, please give details about the person you care for:                                                            

  19. Full Name
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  20. Address
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  21. Telephone Number
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  22. Relationship to you
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  23.  
  1. Please help us update your HEALTH Record:                                                                             

  2. Your Height
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        Feet & Inches or CM

  3. Your Weight
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       Stone or KG's

  4. Your Waist Measurement
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       Inches or CM

  5. Do You Smoke / Given Up?
    Please specify your position in the company

  6. If you have selected Yes please give details:                                                                                                          

  7. How Many / day?
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  8. How Many Years Smoking?
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  9. If you have selected Given Up please give details:                                                                                           

  10. How Many / day?
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  11. How Many Years Smoked?
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  12. When Gave Up (year)
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  13. We strongly advise all smokers to stop smoking. We offer Smoking Cessation Support sessions - please enquire at reception if you require more information.

  14. Do you have a family history of heart disease? (father or brother under 55 years / mother or sister under 65 years)

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  16. Please tick if you have a family history of any of the following                                                            

  17. Stroke
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  18. Raised Blood Pressure
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  19. Diabetes
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  20. Cancer
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  21.  

  1. Please tick the box which best describes your ethnicity / language


  2. White
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  3. White Other (C)
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  4. Mixed
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  5. Mixed Other (G)
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  6. Asian or British Asian
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  7. Asian Other (L)
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  8. Black or Black British
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  9. Black Other (P)
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  10. Other Ethnic Group
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  11. Other Ethnic (S)
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  12. Invalid Input

  13. Please State First Language
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  14.  
  1. Alcohol Consumption

  2. Do you drink alcohol?
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  3. If YES weekly consumption
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  4. If NO have you drunk in the past? Is so, how much in an average week?

  5. Units per week

  6. Date stopped drinking


  7. Fast Alcohol Screening Test

  8. How often do you have 8 (men) / 6 (women) or more units on one occasion?                                                               

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  10. Only answer the following questions if your answer above is monthly or less
                                                                                                                                                         

  11. How often in the last year have you not been able to remember what happened when drinking the night before?


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  13. How often in the last year have you failed to do what was expected of you because of drinking?

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  15. Has a relative / friend / doctor / health worker been concerned about your drinking or advised you to cut down?


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  17. If your total points above is greater than 3, please complete the Alcohol Users Audit Questionnaire on the next page.

  18.  
  1. Alcohol Users Audit Questionnaire

  2. How often do you have a drink that contains alcohol?                                                                                     

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  4. How many standard units do you have on a typical day when you are drinking?                                                              

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  6. How often do you have 6 or more standard drinks on one occasion?                                                                           

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  8. How often in the last year have you found you were not able to stop drinking once you had started?

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  10. How often in the last year have you failed to do what was expected of you because of drinking?

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  12. How often in the last year have you needed an alcoholic drink in the morning to get you going?

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  14. How often in the last year have you had a feeling of guilt or regret after drinking?                              

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  16. How often in the last year have you not been able to remember what happened when drinking the night before?

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  18. Have you or someone else been injured as a result of your drinking?                                              

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  20. Has a relative / friend / doctor / health worker been concerned about your drinking or advised you to cut down?

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  22. Please Repeat
    Please Repeat
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