Adult Health Questionnaire

Please complete this health questionnaire and submit with your registration form.

Last Updated: 08/07/2024

About you

Next of kin or emergency contact

Please provide details of your next of kin or a person we should contact in case of any emergency with you.

Name *

Relationship to you *

Contact telephone number *

Your health history

Please list any long term illnesses, accidents, operations, and diagnosed medical problems you have. Please write none if you have nothing to list. *

Please list any allergies or adverse reactions you have to foods, medicines or other things. Please write none if you don't have any. *

Please list any medications you are taking regularly. Please write none if you don't take any. *

For female patients, when was your last smear test and what was the result?

Please tell us about your smoking habits. *

If you currently smoke or used to smoke please tell us what and how many per day, and if applicable when you gave up.

How often do you drink alcohol? *

How many standard alcoholic drinks do you have on a typical day when you are drinking? *

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

What is your height? *

What is your weight? *

Family history

Please tell us about any significant health problems in your close family.

Asthma (tell us which relations have this)

COPD (tell us which relations have this)

Epilepsy (tell us which relations have this)

Heart attack or heart failure (tell us which relations have this)

Stroke (tell us which relations have this)

High blood pressure (tell us which relations have this)

Diabetes (tell us which relations have this)

Depression (tell us which relations have this)

Consents and inclusion

Please let us know how we can keep in touch with you about your health and care.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Mount Road Surgery website