New Patient Health Questionnaire 

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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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