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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.

Patient Health Questionnaire
Smoking Status
Drinking Status
General Measurements & Blood Pressure
In feet and inches
In Stones and Pounds
In inches
Medical Conditions

Do you have or have ever suffered from any of the following? If yes, please provide 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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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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