Long Lane Medical Centre :: Medical Questionnaire

If you have a few spare minutes, please take the time to fill in this online questionnaire as we are always looking to improve the information that we keep regarding our pations to ensure that we are providing the best possible services. This information will be used to update your medical record.

The prescriber number is the number that you use to order your repeat prescriptions.

The information that you enter will never be passed on to any third parties unless you request that information to be passed on yourself.

Prescriber Number

Date of Birth

Occupation

Ethnicity

Spoken Language

Height in Metres

Weight in kg

Alcohol consumption in Units per week
1 Unit = Glass of beer, Glass of wine or Single measure of spirits

Smoker

If so, how many cigs/oz tobacco per day?

Family History

		Stroke
		Emphysema
		Asthma
		High Blood Pressure
		Heart Disease
		Epilepsy
		Diabetes

Diet

Exercise Level

Please list any allergies you have and describe what happens (ie. Swollen Face / Rash / Diarrhoea / Vomiting / Nausea)

Contraception (female only)

Cervical Smear (female only) When was your last smear?

What was the result?

Please enter any further health details you would consider relevant in the space provided