Patient Health Questionnaire

Welcome to the practice. To enable us to provide you with the best possible medical care, we would be obliged if you would complete the following short questionnaire. All details are confidential and we will not share the data with anyone else. Please complete this questionnaire as fully as possible.

We offer all new patients over the age of 15 years the opportunity of an appointment with our Health Care Assistant to check your blood pressure, review your smoking and alcohol consumptions and offer healthy eating advice.

Please ask at reception if you would like a New Patient Health Check. We particularly recommend this for all patients aged 40 years and over.

We hold your records in the strictest confidence, regardless of whether they are electronic or on paper. We take all reasonable precautions to prevent unauthorised access to your records, however they are stored.

Any information that may identify you is only shared with the practice team, or, if you are referred to hospital, to the clinician who will be treating you. We will only share information about you with anyone else if you give your permission in writing.

Burley Park Patient Health Questionnaire
Gender *
Is this the gender you were assigned at birth? *
Sexual Orientation *

Your Ethnicity

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.

A) White
B) Mixed
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.

Can you speak English?

Smoking Status

Are you…
Are you interested in stopping smoking?

(Reception can provide you with an information sheet outlining the services provided within the surgery and locally)

Alcohol Consumption

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

Do you drink alcohol?

(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
Trouble relaxing
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?

Medical Details

Do you have, or suffer from, any of the following conditions?


Are you on any regular medication?

Communication Needs

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?


Are you pregnant?

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.

Text Reminders

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

Online services

(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?

Patient Participation

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.

If you 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.