Padiham Medical Centre

An award winning GP Practice, serving over 13,000 patients with a full range of enhanced services.

New Patient Health Questionnaire for Adults

New Patient Health Questionnaire for Adults
Your Contact Details
Address
City
State/Province
Zip/Postal
Country
Information About You
Ethnic Group
Previous GP
Address
City
State/Province
Zip/Postal
Country
Medical Information
Have you ever suffered from? (tick as appropriate)
Have you ever suffered from? (tick as appropriate)

Carers
Will
(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
Women
Smoking
Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits

Family History
Next of Kin
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Contacting You