NEW PATIENT CONFIDENTIAL QUESTIONNAIRE - Easygp.net

NEW PATIENT CONFIDENTIAL QUESTIONNAIREPage 3FAMILY MEDICAL HISTORYDo any illnesses run in the family such as: Diabetes, Heart Disease, Blood Pressure,Asthma, Glaucoma, Stroke?(Please add age at onset of serious illness or death)FatherMotherBrothersSistersIf AliveIf not AliveALCOHOLHow often do you have a drink containing alcohol?Never Monthly or less 2-4 times a month2-3 times a week 4 or more times a weekHow many standard drinks containing alcohol do you have on a typical day?1 or 2 3 or 4 5 or 6 7 to 9 10 or moreHow often do you have 6 or more drinks on one occasion?Never Less than monthly Monthly Weekly Daily or almost dailySOCIALAre you caring for a partner / relative / friend / or person who cannot manage without helpbecause of illness / age / disability of any kind? Yes NoIf Yes please give name and age of person (s) you care for______________________________________________________________________________________________________________________________________________Violet Hill House, Violet Hill Road, Stowmarket IP14 1NL Tel 01449 776000www.stowhealth.com