Lifestyle Questionnaire

Lifestyle and Wellbeing Questionnaire

We are always looking for ways to improve the quality of care that we provide to you, so from time to time we ask you to complete questionnaires like this. The answers you provide help us to advise you about your health and wellbeing.

Please do not hesitate to ask if you have any questions.

ABOUT YOU

The information you provide will help your practice and provider to plan and improve your health care services

Date *

First name *

Surname *

Date of Birth *

Primary contact number? *

It is important that the contact number provided is your own to ensure the accurate and confidential delivery of all communications pertaining to your healthcare
Communications include notifications regarding test results, appointment reminders and other health information.

I acknowledge and understand that the contact number provided will be utilised for health-related communications until I notify the practice and update it accordingly *

If contact number provided is not your own, please specifiy the nature of relationship between yourself and contact

Occupation

How do you describe your gender? Gender refers to current gender, which may be different to sex recorded at birth and may be different to what is indicated on legal documents. Please select one box *

What ethnicity (ancestral background) or culture do you identify with?

What language do you use at home?

If not English, Would you like us to organise a translator for you during a consultation?

YesNo

Skip the next two questions if answered No

Which language would you like the translator to use?

Would you like health information emailed/printed out for you in this language?

YesNo

Family History

Please note close relatives are parents, children, brothers, sisters, grandparents, aunts, uncles

General Health

In general, how would you rate your health?

Do you have any allergies?

YesNo

If Yes; please specify and provide the reaction.

Are you a carer for someone with a health issue?

YesNo

If yes; who do you care for?

What is their relation to you?

Are you being cared for?

YesNo

If yes, who cares for you?

What is their relation to you?

What is the best phone number to contact your carer if required?

Smoking and Alcohol

2. If you drink alcohol, how many drinks do you normally have?

Usually one234 or more

3. How many times have you used a recreational drug or used a prescription medication for non-medical reasons?

4. With the following question, please select the rating that best represents your experience during the last year

5. Smoking Status

Non SmokerEx-SmokerSmoker

Skip next to Q6 question if Non-Smoker

When approximately did you start smoking?

Ex-Smokers: When approximately did you stop smoking?

Smoker: Cigarettes per day?

6. Do you vape?

NoYesHave previously but have quit

Skip to submit if answered No

If no you longer vape, when approximately did you stop?

When approximately did you start vaping?

Signature

Clear