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Patient Health Questionnaire

To help us keep your medical record up-to-date, we would be grateful if you would take a few minutes to complete our Health Questionnaire. The information requested is basic and is of course confidential.

Additionally, the Department of Health has asked all G.P practices to ascertain the smoking habits of their patients so that services and resources can be directed to those patients wishing to quit.

It is therefore important that patients completing these forms confirm whether or not they are a current smoker, a past smoker or have never smoked tobacco.

If you do not wish to complete the medical records update online, please contact us and we will arrange a paper copy to be sent to you.

1Patient Health Questionnaire

2Smoking Status

3Drinking Status

4General Measurements & Blood Pressure

In feet and inches
In Stones and Pounds
In inches

5Medical Conditions

Do you have or have ever suffered from any of the following? If yes, please provide date of first diagnosis

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Your Neighbourhood Professionals. Just a Click Away! Counselling: why wait for a NHS appointment? Contact a private counsellor today J M F Wellbing, Fitness & Nutrition
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Renfrew Health & Social Work Centre, 10 Ferry Road, Renfrew, PA4 8RU
  • Telephone 0141 207 7480
Practice Website supplied by Oldroyd Publishing Group
Your Neighbourhood Professionals. Just a Click Away! Counselling: why wait for a NHS appointment? Contact a private counsellor today J M F Wellbing, Fitness & Nutrition
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