Health Questionnaire - Charles Street Surgery

	Health Questionnaire Please try to answer as many of the questions as you can, even if you think they are not relevant to you, or the answers are unchanged from previous information held. "*" denotes a required field.

	Personal Details


	Smoking


	Physical Attributes


	Alcohol


	General Well-being
	To help us identify the effect of some medical conditions on “moods” please answer these questions.


	Exercise


	Ethnic Origin
	Some ethnic groups are more at risk from certain health conditions than others. Please indicate your ethnic group to help your doctor to assess your needs better.

	Specific Medical Conditions
	Epilepsy *

Surname *

Initials *

Date of Birth *

Smoking Status

If Ex-Smoker, when did you quit?

If Ex Smoker, Daily intake at the time of quitting

If Current Smoker, Daily intake

Height
(metres)

Weight
(kg)

How many units a week, approximately?

During the last month, have you often been bothered by feeling down, depressed or hopeless?

During the last month have you often been bothered by having little interest or pleasure in doing things?

Please indicate if you take any regular exercise (at least 20 minutes)

Please select one:

Please indicate when you last had a seizure:

If you know your height please key in the format 02.00 metres.

If you know your weight please key in the format 83.50 kilos.

A unit is approx. a small glass of wine or half-pint of beer.

Yes