V6 New Patient Questionnaire

Title *

Full name *

Previous Surname *

Date of Birth *

NHS Number

Address *

Postcode *

Landline Number

Mobile Number

Consent to receive SMS Text

Yes No

If contacted by phone can we leave a message (we can only leave a message if your answer message is personalised)

Yes No

Email Address *

Information About You

Medical Information

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking?

Yes No

Alcohol

1 unit of alcohol = 1/2 pint of regular beer, lager or cider or 1/2 a small glass of wine or a single measure of spirit, sherry or aperitifs

1.5 units of alcohol = 1 Alcopop or a 275ml bottle of regular lager

2 units of alcohol = 1/2 pint of "strong or premium" beer, lager or cider

3 units of alcohol = 250ml glass of wine (12%) or 1 pint of "strong or premium" beer, lager or cider

4 units of alcohol = 440ml can of "super strength" lager

9 units of alcohol = 75cl Bottle of wine (12%)

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Further Information