Patient Health Questionnaire

First name *
Last name *
Preferred name
Date of birth *
Gender *
NHI (if known)
Phone *
Email *
Address *
GP name
GP practice
Occupation
Ethnicity
Next of kin - Name *
Next of kin - Relationship *
Next of kin - Contact details *
Drug or food allergies *

Past Medical History - Please select all that apply

Other medical problems
Do you drink alcohol or take recreational drugs
Height (cm)
Weight (kg)
Current medication

Recent history

Do you or your blood relatives have, or have they had:

We undertake to only collect information which is appropriate to your care, only to use this information for the intended purposes, to keep the information for the intended purpose, to keep the information in our computer system, only to allow authorised staff to use that information, only to pass onto the government bodies that information to which they are legally entitled, to allow you to check the accuracy of any information about you and to submit written corrections which you feel appropriate. I agree to settle my account in full when personally paying or where I do not have prior approval from my insurer. I understand I am responsible for any outstanding balance if my procedure is not fully covered by insurance, ACC or any other contract. I have read the above information and understand and agree: *