Health Questionnaire

Having up to date health details about our patients is vital in providing the best healthcare possible.

If you have received a health questionnaire in the post, or have been given one in the surgery, you can fill this out here on the website and send it to us directly to save you filling it out on paper and sending it back to us.

If you have not received a health questionnaire from us, please do take the time to fill this in, it will help us immensely, thank you.
 

 

Please fill in all the boxes.

 

Use the TAB button on your keyboard, or use your mouse to the next box. Please do NOT hit Enter on your keyboard. If you do this, you will be told you have not filled in the form correctly and asked to do it again.

Important
You must accept the Terms & Conditions of this service and tick the checkbox at the bottom of this form. You will not be able to use this form without accepting our Terms & Conditions of Service.

Your Details

First Name
*

Surname*

Phone Number

E-mail Address

 

 


 

 

Basics

Your Date of Birth                     Weight                                        Height
                             

Have you had your Blood Pressure checked in the last 10 years?

Have you had a Tetanus Jab in the last 10 years?

What is your Occupation?

Do you take any form of exercise?

 

Lifestyle

Do you Smoke?

If you smoke, how much do you smoke per day?

If you smoke, what do you smoke?

Have you previously stopped smoking, if so when?

If you are a smoker and would like help giving up smoking, we have a smoking cessation clinic set up at the practice, would you like more information on this?

How many units of alcohol do you drink on an average week?

 

History

Has anyone in your family under the age of 60 had:

 - A Heart Attack / Heart Disease
 - Stroke
 - Blood Clot
 - Cancer

Do you have any past medical history that you think may be valuable to us?

Do you have any further comments that you think may be valuable?

 

Other

Do you have any known allergies?

What is your Ethnic Group?
         Other:

Ethnic Information Refused

 

Terms & Conditions

I accept the terms & conditions of Service*

 

Thank you for taking the time to fill out this health questionnaire.

 

Copyright 2009 Dartmouth Medical Practice