New Patient Health Questionnaire

New Patient Health Q’s
Title: *
Address *


Preferred method of Communication

Communication Needs

Do you speak English?
Do you read English?
Are you a British Sign Language user?


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)

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?
Do you have access to secure housing?
What is your current immigration status?


Do you have caring responsibilities?
Do you have a carer?

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?
Have you entered UK within the last 5 years?
Are you aged 16-36 years?
Is there any history of Tuberculosis in the past?
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.