Patient Health Questionnaire

To help us keep your medical record up-to-date, we would be grateful if you would take a few minutes to complete our Health Questionnaire. The information requested is basic and is of course confidential.

Additionally, the Department of Health has asked all G.P practices to ascertain the smoking habits of their patients so that services and resources can be directed to those patients wishing to quit.

It is therefore important that patients completing these forms confirm whether or not they are a current smoker, a past smoker or have never smoked tobacco.

If you do not wish to complete the medical records update online, please contact us and we will arrange a paper copy to be sent to you.

First Name

Surname

Date of Birth

Home Number

Mobile Number

Languages Spoken

Ethnicity

Do you regulary care for someone who is disabled or chronically ill?

Smoking Status

What is your Smoking Status?

How many do you smoke a day?

Would you like our assistance in helping you to stop smoking?

Drinking Status

Average Weekly Pints of Beer or Cider?

Average Weekly Small Glasses of Wine?

Average Weekly Single Shorts?

General Measurements & Blood Pressure

What is your Height?In feet and inches

What is your Weight?In Stones and Pounds

What is your Waist Size?In inches

If you monitor your blood pressure at home, what was your last recording?

Medical Conditions

Do you have or have ever suffered from any of the following? If yes, please provide date of first diagnosis

Asthma

Date of first diagnosis

Chronic Lung Disease

Date of first diagnosis

High Blood Pressure

Date of first diagnosis

Cancer

Date of first diagnosis

Diabetes

Date of first diagnosis

Angina

Date of first diagnosis

Heart Attack

Date of first diagnosis

Stroke

Date of first diagnosis

Mental Illness (Excluding Depression)

Date of first diagnosis

Hypothyroidism (Underactive Thyroid)

Date of first diagnosis

Epilepsy

Date of first diagnosis

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Braehead Medical Practice • Renfrew Health and Social Work Centre, 10 Ferry Road, Renfrew, PA4 8RU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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