New patient health questionnaire

Patient's details [Manylion y claf]

Surname [Cyfenw](Required)

Forename/s [Enw(au) cyntaf](Required)

NHS Number (if known) [Rhif GIG (os ydych chi’n ei wybod)]

Date of birth [Dyddiad geni](Required)

Day

Month

Year

Marital status [Statws priodasol](Required)

Address [Cyfeiriad](Required)

Postcode [Cod Post](Required)

Home telephone number [Rhif ffôn cartref](Required)

Mobile (if aged 16 and over) [Rhif ffôn symudol (os ydych yn 16 oed neu’n hŷn)]

Ethnicity [Ethnigrwydd](Required)

Gender [Rhywedd](Required)

Language preference [Nodwch eich dewis iaith](Required)

Welsh [Cymraeg]

English [Saesneg]

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccination reminders, to let you know that your prescription or your sick note is ready for collection and anything else relevant to your healthcare? [Ydych chi’n cydsynio i’r practis gysylltu â chi drwy neges destun er mwyn eich atgoffa am apwyntiad, eich gwahodd i archwiliad iechyd, eich atgoffa am frechiad, rhoi gwybod ichi fod eich presgripsiwn neu eich nodyn salwch yn barod i’w gasglu, ac unrhyw beth arall sy’n berthnasol i’ch gofal iechyd?](Required)

Yes [Ydw]

No [Nac ydw]

We have an electronic method of contact available for patients to contact the surgery for non urgent requests – do you consent for us to correspond with you via this method and supply us with a preferred e-mail address for this purpose? [Mae gennym ddull electronig o gysylltu y mae cleifion yn gallu ei ddefnyddio i gysylltu â’r feddygfa os oes ganddynt ymholiadau nad ydynt yn frys. Ydych chi’n cydsynio i ni gysylltu â chi drwy’r dull hwn, a rhoi cyfeiriad e-bost yr hoffech chi inni ei ddefnyddio at y diben hwn?](Required)

Yes [Ydw]

No [Nac ydw]

Email address [Cyfeiriad e-bost]

Enter Email Confirm Email

Smoking [Ysmygu]

Do you smoke? [Ydych chi’n ysmygu?](Required)

Yes [Ydw]

No [Nac ydw]

If yes, how many cigarettes per day?/Ounces of tobacco per day? [Os ydych chi, sawl sigarét y diwrnod?/owns o dybaco y diwrnod?]

Alcohol [Alcohol]

For the following questions please answer to the best of your knowledge. We have provided a basic guide to alcohol content below to assist your completion: [Atebwch y cwestiynau canlynol y gorau ag y gallwch chi, hyd eithaf eich gwybodaeth. Isod, mae canllaw syml ar faint o alcohol mae diodydd gwahanol yn ei gynnwys er mwyn eich helpu i roi ateb:]

A 750ml bottle of wine contains 10 units
[Mae potel o win 750ml yn cynnwys 10 uned]

A standard (175ml) glass of wine contains 2 units
[Mae gwydraid safonol (175ml) o win yn cynnwys 2 uned]

A single small shot of spirits (25ml) contains 1 unit
[Mae un joch bach o wirodydd (25ml) yn cynnwys 1 uned]

A standard 70cl bottle of spirits contains 28 units
[Mae potel safonol (70cl) o wirodydd yn cynnwys 28 uned]

A pint of 3.6% strength lager/beer/cider contains 2 units
[Mae peint o lager / cwrw / seidr â chryfder o 3.6% yn cynnwys 2 uned]

A pint of 5.2% strength lager/beer/cider contains 3 units
[Mae peint o lager / cwrw / seidr â chryfder o 5.2% yn cynnwys 3 uned]

Find out more about alcohol units on the NHS website [Unedau alcohol – GIG]

How many units of alcohol do you drink a week? [Sawl uned o alcohol ydych chi’n eu hyfed bob wythnos?]

Height and Weight [Taldra a phwysau]

Please tell us your most recent measurements for the following (if known) [Nodwch eich mesuriadau diweddaraf ar gyfer y canlynol (os ydych chi’n eu gwybod)] Please note, we may contact you to offer you support or advice if appropriate based on your submission. [Sylwer: Mae’n bosib y gwnawn ni gysylltu â chi i gynnig cymorth neu gyngor, os yw’n briodol, ar sail eich atebion.]

Height [Taldra]

Weight [Pwysau]

Further information

NB: The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. [Sylwer: Gall yr wybodaeth ganlynol rydych chi’n ei rhoi inni ein helpu i ddarparu gofal da ichi wrth inni aros am eich cofnodion meddygol blaenorol.]

Family History [Hanes teuluol]

Is there any of the following in your family (father, mother, brother, sister) before the age of 65?

Heart disease [Clefyd y galon]

Stroke [Strôc]

Cancer [Canser]

Site of cancer? [Ble mae’r canser?]

Which family member? [Pa aelod o’r teulu?]

Medication [Meddyginiaeth]

Please give details of any medication which you take (prescribed or otherwise). [Nodwch fanylion unrhyw feddyginiaeth rydych chi’n ei chymryd (ar bresgripsiwn neu beidio)]

Please attach or forward us your most recent repeat medication slip if you have one. [Amgaewch eich slip meddyginiaeth reolaidd ddiweddaraf, neu anfonwch ef ymlaen atom, os oes gennych chi un.]

Allergies [Alergeddau]

Do you have any allergies? [Oes gennych chi unrhyw alergeddau?]

Yes [Oes]

No [Nac oes]

If Yes, please give details: [Os Oes, rhowch fanylion:]

Past Medical History [Hanes meddygol]

Please give details of any treatments/medical conditions: [Rhowch fanylion unrhyw driniaethau / cyflyrau meddygol:]

Carers [Gofalwyr]

Do you need/have anyone who looks after you or your daily needs as Carer? [Oes arnoch chi angen / oes gennych chi rywun sy’n gofalu amdanoch chi neu’n gofalu am eich anghenion dyddiol, fel gofalwr?]

Yes [Oes]

No [Nac oes]

If Yes, would you like them to deal with your health affairs here? [Os Oes, ydych chi eisiau iddyn nhw ddelio â’ch materion iechyd yma?]

Yes [Ydw]

No [Nac ydw]

(A member of reception staff can help with these arrangements) [(Gall aelod o staff y dderbynfa helpu i drefnu hyn)]

Do you care for anyone else? [Ydych chi’n gofalu am unrhyw un arall?]

Yes [Ydw]

No [Nac ydw]

(If Yes, please ask the reception staff about Carers support) [(Os ydych, gofynnwch i aelod o staff y dderbynfa ynglŷn â chymorth i ofalwyr]

Military Veteran [Cyn-filwr]

Have you ever served in the Armed Forces? [Ydych chi wedi gwasanaethu yn y lluoedd arfog erioed?]

Yes [Ydw]

No [Nac ydw]

Communication [Cyfathrebu]

Do you have any communication/information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you? [Oes gennych chi unrhyw anghenion o ran cyfathrebu / gwybodaeth yn ymwneud â cholli synhwyrau? Os oes, beth ydyn nhw a sut hoffech chi inni gyfathrebu â chi?]

Privacy consent

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

I agree to the privacy policy.

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

Patient's details [Manylion y claf]

Smoking [Ysmygu]

Alcohol [Alcohol]

Height and Weight [Taldra a phwysau]

Further information

Family History [Hanes teuluol]

Medication [Meddyginiaeth]

Allergies [Alergeddau]

Past Medical History [Hanes meddygol]

Carers [Gofalwyr]

Military Veteran [Cyn-filwr]

Communication [Cyfathrebu]

Privacy consent

Thank you for completing this questionnaire. [Diolch am gwblhau’r holiadur.]

Helpful links

Further Info