Newbury Street Practice Questionnaire

It may take some time before we receive your medical records from you previous practice. In order for us to provide better medical care, please complete as many questions as possible and provide as much information as you can.

Last Updated: 26/08/2021

Personal Details

























Armed Forces




Personal Medical History






Alcohol Consumption

A score of 5+ may indicate harmful or hazardous drinking. Pint of regular beer/lager/cider = 2 units, Alcopop or can of lager = 1.5 units, Glass of wine (175ml) = 2 units, Single measure spirit = 1 unit, Bottle of wine = 9 units.



Family History

Thinking of your close family, is there any history of disease such as Asthma, Cancer, Mental Health, Skin Disease, Diabetes, Glaucoma, Heart Disease, High Blood Pressure or Stroke?

Carer






General Health and Welfare Information







Donor Register

If you would like to register to be a blood donor or opt out of the organ donor register, please go to our Services page.

Online Services

To register for access to your medical notes please complete the online access form