New Patient Health Questionnaire New Patient Health Questionnaire Your Informaton Names * Names First First Middle Middle Last Last Title * Mr Mrs Miss Ms Mx Other (please specify)Other (please specify) Date of Birth * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Contact Information Mobile Number Home Number Occupation Work Number (if applicable) Email Next of Kin Information Next of Kin Name * Next of Kin Name First First Last Last Relationship to you * Contact Number * Address * Identity Gender * FemaleMaleNon-BinaryOther Gender Preferred Pronouns * She/Her/Hers He/Him/His They/Them/Theirs OtherOther Is your gender identity the same as the gender you were assigned at birth? * Yes No If you answered ‘no’, what is your birth gender? FemaleMaleIntersex Sexual Orientation I do not wish to discloseHeterosexualBisexual/PansexualHomosexualAsexualUnsureOther Sexual Orientation Are you in a relationship? Yes No Ethnicity * I do not wish to discloseClick here to type Ethnicity Please list all languages you speak: * Do you require an interpreter? * No Yes (please specify which language)Yes (please specify which language) Religion I do not wish to discloseClick here to type Religion Please state any religious or cultural needs you have: Medical Information Height Weight Blood Pressure Name and Address of Previous GP: How many children do you have? 012345678910+ Please provide their names and dates of birth: Do you have any pre-existing medical conditions? * No Yes (please specify)Yes (please specify) Do you have any allergies? * No Yes (please specify)Yes (please specify) Are you taking any medication? * No Yes (please specify)Yes (please specify) Which pharmacy would you like your medication to be sent to? * Manor Pharmacy, Chandler House, Poolstock Lane, WN3 5HLManor Pharmacy, Boston House, Wigan Health Centre, WN6 7LBManor Pharmacy, Worsley Mesnes Drive, WN3 5TEManor Pharmacy, Gathurst Lane, WN6 8HABoots, The Concourse, WN8 6NDBoots, Holmes House Avenue, WN3 6JABoots, Loire Drive, Robin Park, WN5 0UHBoots, Ormskirk Road, WN5 8ATRowlands Pharmacy, Hillside Health Centre, Tanhouse Road, WN8 6DSRowlands Pharmacy, Birleywood, WN8 9HRRowlands Pharmacy, Marsh Green, WN5 0PURowlands Pharmacy, Dingle Road, WN8 0ENWell Pharmacy, Ormskirk Road, WN5 9EDWell Pharmacy, Church Street, WN5 8TQAllied Pharmacy, Mesnes Street, WN1 1QJAppley Bridge Pharmacy, Woodnook Road, WN6 9JRAsda Pharmacy, Soho Street, WN5 0XABradshaw Street Pharmacy, Bradshaw Street, WN5 0ABCohens Chemist, Orrell Road, WN5 8NBEngland Pharmacy, Gidlow Lane, WN6 7PGGeorge Wilson, Pemberton Primary Care, Resource Centre, WN5 9QXHawkley Pharmacy, Carr Lane, WN3 5NDHollowood Chemist, Mesnes Street, WN1 1QPLloydsPharmacy, Worthington Way, WN3 6XEShevington Community Pharmacy, The Surgery, WN6 8ET Houghton Lane,Other (please specify) Which pharmacy would you like your medication to be sent to? Would you be interested in joining our PPG? (Click the button below for more information) Yes No Submit Start Over If you are human, leave this field blank. PPG Information
