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Paxton Medical Group

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PATCHES (online consultation)
New Patients
Appointments
Prescriptions
Services
Contraception
Patient Record
Health Advice
Online Forms
Leave a Review
NHS 111 Online
Cervical Screening (smears)

Home
Opening Hours
Our Staff
Contact Us

General Health & Lifestyle Questionnaire

This health & lifestyle questionnaire covers all the basic information surgeries need to keep your medical record up to date and accurate.

Last Updated: 15/03/2022

Personal Details

Please ensure your personal detail are correct before submitting. Please remember to inform the surgery should you change your address, phone number or email address.

Full Name *

Date Of Birth *

Telephone Number *

Email address *

Health Questionnaire

Standing Height *

Weight *

Smoking Status *

Non-Smoker

Ex Smoker

Smoker 1-5 cigarettes a day

Smoker 5-10 cigarettes a day

Smoker 10-20 cigarettes a day

Smoker 20+ cigarettes a day

User of Electronic smoking device (Vape)

If you are a smoker, would you like any help / advice to help you quit? *

Yes

No

Not applicable

Alcohol Consumption (How many units do you consume per week on average) *

T-Total - (None Drinker)

1-10 units per week

10-20 units per week

20+ units per week

Unsure but feel like it is to much

Unsure but not in excess

Would you like any help / advice to help stop drinking?

Yes

No

Not applicable

Please use this section to let us know anything else you think may be important

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