Date Of Birth
Is this the gender you were assigned at birth?
Next of Kin (Emergency Contact)
Their Relationship to you
Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions. Please choose one section from A to E then tick the appropriate box to indicate your cultural background.
C) Asian or British Asian
D) Black or Black British
E) Chinese or other ethnic group
The above questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.
What language do you speak at home?
What / How much do you smoke per day?
Are you interested in stopping smoking?
(Reception can provide you with an information sheet outlining the services provided within the surgery and locally)
Because alcohol can affect your health and can interfere with certain medications and treatments, it is important that we ask you some questions about your use of alcohol.
Your answer will remain confidential so please be honest
If you answered “yes”, approximately how many units do you drink in an average week?
(Please see the list below for some examples of the average alcoholic content of some common drinks)
Bottle (75cl) of wine – 10 units
Small (125ml) glass of wine – 1.5 units
Standard (175ml) glass of wine – 2.1 units
Large (250ml) glass of wine – 3 units
Pint of weaker (3.6%) beer – 2 units
Pint of stronger (5.2%) beer – 3 units
Bottle (330ml) of beer – 1.7 units
Can (440ml) of beer – 2 units
Alcopop bottle (275ml) – 1.5 units
Small (25ml) shot of spirits – 1 unit
Large (35ml) shot of spirits – 1.4 units
If you answered “Yes” to the first question, please answer the following short questionnaire, by ticking the appropriate box and placing the score for each answer in the final column:
How often do you have a drink that contains alcohol?
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
The Government advises alcohol consumption should not regularly exceed 3-4 daily units for men and 2-3 daily units for women.
If you scored
5 or more please complete the next sets of questions-if you scored less than 5 on the first set of questions you do not need to answer the next set of questions.
How many times in the last year have you found you were not able to stop drinking once you had started?
How many times in the last year have you failed to do what was expected of you because of drinking?
How many times in the last year have you needed an alcoholic drink in the morning to “get you going”?
How often in the last year have you had a feeling of guilt or regret after drinking?
How often in the last year have you not been able to remember what happened when drinking the night before?
Have you or someone else been injured as a result of your drinking?
Has a relative/friend or health worker been concerned about your drinking and advised you to cut down?
Add the total of the two sets of questions together
0-7= Sensible Drinking
8-15= Hazardous drinking
16-19= Harmful drinking
20+= Possible Dependency
If you scored more than 8 points in total on the last test, or are worried about the amount you drink you can call Alcohol Dependency Services (ADS) on 0113 2470111 who can provide help or advice on safe drinking levels.
Alternatively, we have an alcohol worker who works in the practice each week
Would you like help or advice on safe drinking levels from them?
If you scored more than 8 points, please complete the following questionnaire: Over the last 2 weeks how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Your score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively, and adding together the scores for the seven questions.
Scores of 5, 10, and 15 are taken as the cut off points for mild, moderate, and severe anxiety, respectively.
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead, or of hurting yourself in some way?
Do you have, or suffer from, any of the following conditions?
Are you on any regular medication?
If yes, please specify below (you will need to attend for an appointment with one of the GPs before we can re-start your course of medication)
Please nominate a Pharmacy of your choice so we can send your prescriptions electronically to them
We will always try to provide correspondence and information in formats patients will find easy to understand-if you have any communication requirements (e.g. if you are blind, deaf or have difficulty reading or if your require signing interpreters etc.) please let us know below:
Leeds has a higher than average HIV rate so we therefore offer all new patients a HIV test. If you would like to have this test please book a blood appointment at reception.
Cervical Smear History
(Women; trans men and non-binary people with a cervix or other people with a cervix between 25-64 years old only)
Have you had a Cervical Smear?
If “Yes”, when was this carried out (approx)?
If you are pregnant, please tick below and provide us with the approximate number of weeks.
How many weeks along ?
Armed Forces Service
Please tick below if you are an ex member of the UK armed forces, or if you are the dependent of a serving or ex member of the UK armed forces.
We currently use an automated text reminder service for appointments. If you would prefer not to use this service you can opt out.
I would like reminders for appointments
Mobile Number (If not already supplied)
(making appointments, requesting medication and view your medical records online)
At registration we offer all patients an online account that allows them to book appointments and request medication online. In addition to appointment booking and requesting medication, would you like online access to your medical records?
We are looking for a group of patients that we can contact when we have questions or ideas about the future direction of the practice. If you would like to be included in this group, please ask at reception for a form.
Summary Care Record (SCR) Consent
An SCR is a secure electronic copy of portions of your medical record that will be available to Hospitals or out of hours GP services should they require it in the event of an emergency.
do not wish to have an SCR created please complete the section below and request and complete an SCR consent form from reception. If you have no objections to having an SCR created you do not need to complete this section-an SCR will automatically be created for you.
If you require more information regarding SCR before making your decision please contact the NHS Care Records Service on 0845 603 8510
Thank you for your time in completing this questionnaire-this will help us to ensure you receive the best possible care.