Health Questionnaire – 12 to 15 Health Questionnaire - 12 to 15 Personal Details Title * Name * Name First First Last Last Date of Birth * Gender * Male Female Non-binary Address * Address House name / Flat No House name / Flat No Street address Street 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 Who else lives in your household? * Are you an unpaid carer for someone? * Yes No If yes, please specify HOME Phone Number Do you consent to have messages left on voicemail? Yes No Email Address * Do you consent to use of your email as a way for us to contact you? * Yes No Owner of address? * Child Parent/Guardian MOBILE Phone number Do you consent to have messages left on voicemail? Yes No Owner of mobile? * Child Parent/Guardian Do you consent to allow the Practice to text you information and reminders to your mobile number? No Yes *please note this will only apply to those aged 14+ who own their own mobile – we do not text information about a child to a parent Next of Kin * Medication Are you on any regular medication (incl contraceptive pill)? * Yes No ***** (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) ***** Please state name and dose of all you current medications Are you allergic to any medications? * Yes No If yes, please state name of medication and type of reaction you had Medical History Do you have any of the following conditions: High Blood Pressure * Yes No Approx date of diagnosis: Diabetes * Yes No Approx date of diagnosis: Heart Disease * Yes No Approx date of diagnosis: Angina * Yes No Approx date of diagnosis: Epilepsy * Yes No Approx date of diagnosis: Stroke * Yes No Approx date of diagnosis: Cancer * Yes No Approx date of diagnosis: Asthma * Yes No Approx date of diagnosis: If asthmatic, have you used your inhaler in the last 12 months? Yes No Please give details of any other illnesses, accidents, hospital admissions, investigations or operations you have had: Family History Has a first degree relative (parent or sibling) suffered from any of the following conditions? Cancer * Yes No Who? At what age? Stroke * Yes No Who? At what age? Heart Disease * Yes No Who? At what age? Diabetes * Yes No Who? At what age? Do any other illnesses run in you family? * Yes No If yes, please give details: Please give details of the current state of your family’s health: Age Father State of health Age at death Cause of death Age Mother State of health Age at death Cause of death Age Sibling1 State of health Age at death Cause of death Age Sibling2 State of health Age at death Cause of death Age Sibling3 State of health Age at death Cause of death Age Sibling4 State of health Age at death Cause of death Contact with Other Agencies Under the current Child Health & Wellbeing Guidance, we are obliged to ask the following for all new registrations to the Practice between the ages of 0-16 years. Does anyone in your household currently have contact with any of the following support services? A: Social Word Department * Yes No B: Mental Health Services * Yes No C: Drug/Alcohol Support Services * Yes No If yes to any, please give brief details Ethnicity & Language What is your main spoken language? * Do you need an interpreter or sign language support? * Yes No Choose ONE section from A to G then choose ONE option which best describes your ethnic group or background A: White Scottish English Welsh Northern Irish British Irish Gypsy/Traveller Polish OtherOther B: Mixed or multiple ethnic groups Any mixed or multiple ethnic groupAny mixed or multiple ethnic group C: Asian, Asian Scottish, or Asian British Pakistani, Pakistani Scottish, or Pakistani British Indian, Indian Scottish or Indian British Bangladeshi, Bangladeshi Scottish, or Bangladeshi British Chinese, Chinese Scottish, or Chinese British OtherOther D: African African, African Scottish, or African British OtherOther E: Caribbean or Black Caribbean, Caribbean Scottish, or Caribbean British Black, Black Scottish, Black British OtherOther F: Other ethnic group Arab OtherOther G: Other I would prefer not to say I don't know my ethnicity Confirmation I confirm that I have read and understood this form, and completed it honestly and to the best of my knowledge * Confirm I am * the patient a friend/carer/relative/helper of the patient Your Name Your Name First First Last Last Relationship to the patient? reCAPTCHA If you are human, leave this field blank. 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