ADULT QUESTIONNAIRE

Rutland House Surgery Health Questionnaire for Newly Registered Adult Patients

Personal Details

Do you consent to SMS?

Do you consent to SMS?

Do you have any children?

Do you have any children?

Are you a Carer?

Are you a Carer?

Does someone look after you?

Does someone look after you?

Do you require information about your benefits for Carers?

Do you require information about your benefits for Carers?

Please indicate your ethnicity:

Please indicate your ethnicity:

Family History

Please state which member of your family have any of the following conditions i.e. Mother, Father etc.

Lifestyle

Diet

Diet

Smoking habits?

Smoking habits?

Alcohol

Please complete the following Audit C test:

Unit definition: 1 Glass of Wine = 1.5 Units, 1 Bottle = 10 Units, 1 Pint of Beer = 3 Units, 1 Spirit Measure = 1 Unit

How often do you have a drink containing alcohol?

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when drinking?

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

How often have you had 6 or more units if female, or 8 or more if male on a single occasion in the last year?

How often have you had 6 or more units if female, or 8 or more if male on a single occasion in the last year?

Exercise Status

General

Exercise Status

Sexual Health Lifestyles

Sexual Health Lifestyle

Medical History

Female Patient: Are you taking any contraceptive medications?

Female Patient: Are you taking any contraceptive medications?

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