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New Patient Health Questionnaire
| Patient Information | |
| Family Name: | First & Middle Names: |
| Date of Birth (DD/MM/YYYY): | |
| Gender: Male☐ Female ☐ Non-binary ☐ Gender diverse ☐ Transgender ☐ Different identify ☐ Other: _________ | |
| Height (cm): | Weight (kg): If unsure, please use the scale in the waiting room. |
| Marital status: Single ☐ Partnered ☐ Married ☐ Divorced ☐ Widowed ☐ De facto ☐ | |
| Sexuality: Asexual ☐ Bisexual ☐ Gay ☐ Heterosexual ☐ Homosexual ☐ Lesbian ☐ Pansexual ☐ Queer ☐ Skoliosexual ☐ | |
| Occupation: ________________ Are you an elite athlete? Yes ☐ No ☐ | |
| Smoking: ☐ Never ☐ Ex-smoker ☐ Current smoker Cigarettes per day (if current): ___________________Past smoking history: Quantity per day: Unknown ☐ <1 ☐ 1-9 ☐ 10-19 ☐ 20-39 ☐ 40+ ☐ Year started: __________ Year stopped: ________ Patient would like cessation advice /support: Yes ☐ No ☐ | |
| Alcohol Consumption Non-drinker ☐ Occasionally ☐ Frequent ☐ Days per week: _____ Standard drinks per day: _____ Past alcohol intake: Nil ☐ Occasional ☐ Moderate ☐ Heavy ☐ Year started: __________ Year stopped: ________ | |
| Medical History | |
| Allergies (food/medications/substances): ☐ Yes ☐ No If yes, list allergies & reactions: _______________________________________________ | |
| Major medical conditions: _________________________________________________________ Previous major surgeries: _________________________________________________________ Family Medical History (Please note, this section may contain sensitive information) Mother: ☐ Alive ☐ Deceased — Cause/Year: ____________________________________ Father: ☐ Alive ☐ Deceased — Cause/Year: ____________________________________ No significant family history ☐ Significant Family History: Mother: Diabetes ☐ Hypertension ☐ Heart disease ☐ Stroke ☐ Colon Cancer ☐ Depression ☐ Breast Cancer ☐ Father: Diabetes ☐ Hypertension ☐ Heart disease ☐ Stroke ☐ Colon Cancer ☐ Depression ☐ Breast Cancer ☐ Other Family History: | |
| Current medication/supplement? | |
Please return this completed form to your nurse or doctor. All information is confidential.
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