New Patient Health Questionnaire New Patient Health Q’s Title: * Mr Mrs Miss Ms Dr Other First Names: * Surname: * Date of Birth: * Address * Address Address Address Postcode Postcode City City Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Email Address: Telephone Number: * Mobile Number: Height * Weight * Relationships Family members names and date of births who are registered with Bridgewater Nominated Pharmacy * Preferred method of Communication SMS Email Letter None Preferred Branch * Bridgewater House North Approach Surgery Meriden Surgery Communication Needs Do you speak English? * Yes No Do you read English? * Yes No What is your main spoken language? * Are you a British Sign Language user? * Yes No Disability Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) No known impairment, health condition or learning difference A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy A mental health impairment, such as depression, schizophrenia or anxiety disorder A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches A learning difficulty Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Deaf or hearing impaired Blind or have a visual impairment uncorrected by glasses An impairment, health condition or learning difference that is not listed above Prefer not to say Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications): Armed Forces Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? * Yes No Do you have access to secure housing? Yes No What is your current immigration status? Asylum Seeker Failed Asylum Seeker Carers Do you have caring responsibilities? None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say Do you have a carer? Yes No Latent Tuberculosis Programme Were you born or have you lived more than 6 months in one of the following places? Pakistan, Bangladesh, India, Buhutan, Nepal, Afghanistan, Africa, Philippines, Myanmar, Indonesia? Yes No Have you entered UK within the last 5 years? Yes No Are you aged 16-36 years? Yes No Is there any history of Tuberculosis in the past? Yes No If yes, you may be eligible for Latent Tuberculosis Screening, and we can arrange an appointment for you to discuss with staff and book a blood test. Further information available on request. Signature Signature * Signature on behalf of patient Date * If you are human, leave this field blank. Submit