Not feeling quite like yourself? Take the SHE Health Quiz
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New Patient Questionnaire

Please complete the questions below. Answers to ALL questions are required before pressing the submit at the bottom of the page.  Please answer ‘not applicable‘ if needed, rather than leave an empty box. The more detail you provide, the more we are able to help you.

Name
Including Postcode
(Name , Full practice address including postcode and email- please note the provision of an email address for your GP practice is a requirement before any prescriptions or letters can be arranged )
Have any of your close family members (parents, siblings, children) been diagnosed with any of the following?
(Please tick all that apply and include who in your family was affected, if known)
If you’re unsure, just let us know - we’ll talk through anything during your appointment.
Please provide as much information as possible
Include any details of past surgery's
Including contraception and over the counter medications and supplements
Cycle Length, regularity, symptoms
Please include: number of pregnancies, births, miscarriages, terminations.
If you answered yes to the above, please complete this section
If you answered yes to the above, please complete this section
(Wine/Vodka/Gine etc)
In general how much do you enjoy being physically active?
What makes it difficult for you to exercise?
How long on average do you exercise for each time to break into a light sweat?
When you exert yourself do you experience any of the following?
In the last 7 days how much did pain interfere with your day to day activities?
Pain: In the past 7 days how much did pain interfere with your enjoyment of life?
Nutrition: How often during the week do you eat out in restaurants or order a take away?
Nutrition: How often during the week do you cook meals from scratch – i.e. use raw foods and prepare them to assemble a meal?
Nutrition: How many portions of plant based food do you eat per day - i.e. fruit, vegetables, salads, nuts, seeds
On a scale of 1-10 where 1 means no restraint in eating (eating whatever you want, whenever you want it) and 10 means total restraint (constantly limiting food intake and never ‘giving in’), what number would you give yourself?
Have you ever been diagnosed with an eating disorder?
What type of drink do you drink the most of during the day?
Do you have a medical condition that interferes with your sleep?
How would you rate your sleep overall on a scale of 1-10 (10 being perfect)?
Do you have difficulty getting off to sleep?
Do you wake up during the night?
Do you go to bed at roughly the same time every night?
Do you wake up feeling refreshed?
Emotional Health: How often have you felt a lack of confidence about your ability to handle your personal problems?
Please provide details
Over the past 2 weeks how often have you had trouble relaxing?
Over the past 2 weeks how often have you been worrying about different things?
Over the past 2 weeks how often have you had little interests or pleasure in doing things?
Over the past 2 weeks how often have you had feelings of feeling down, depressed or hopeless?
Social Connections: During the past 2 weeks have you spent time with relatives or other significant adults living outside your home in person ( eg not on face time, online, video or telephone calls)?
Do you have someone to turn to for emotional support?
Do you have someone to turn to for assistance if needed?
Do you consent to receive communications about your healthcare and updates relating to the clinic?
SHE Health will use the information you provide on this form to communicate and to provide updates and marketing. You can change your mind at any time by clicking the unsubscribe link in the footer of any email you receive from us, or by contacting us at info@shehealth.co.uk We will treat your information with respect. For more information about our privacy practices please see our privacy policy. By subscribing, you agree that we may process your information in accordance with these terms.