New Patient Additional Health Information Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other First NamesSurnamePrevious Surname OptionalDate of Birth Day Month Year Gender Female Male Address Street Address Address Line 2 City Postcode Main Contact NumberHome Contact Number OptionalEmail Enter Email Confirm Email DemographicsMarital Status Single, never married Married Civil Partnership Divorced Widowed Separated Which of the following options best describes you? Heterosexual or Straight Gay or Lesbian Bisexual Prefer not to say In another way Sex and gender identity – Which one of the following best describes how you think of yourself? Male (including trans men) Female (including trans women) Non-binary Prefer not to say In another way Is your gender identity the same as the gender you were given at birth? Yes No Prefer not to say What is your main religion? No religion Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Buddhist Hindu Jewish Muslim Sikh Other religion CommunicationDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language?Preferred method of contact video conference email address mobile tel. number home tel. number other Please specifyPlease tick if you do NOT have a mobile telephone number Does not have mobile telephone Optional Digital literacy level Unable to perform information technology activities Optional Difficulty performing information technology activities Optional Able to perform information technology activities Optional Do you have any difficulty understanding information provided to you about your health or treatments you may be receiving? Yes – Unable to demonstrate health literacy No – Able to demonstrate health literacy Prefer not to answer Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalHousingLives alone Lives alone Optional Lives alone – help available Optional Lives alone no help available Optional Lives in a nursing or a residential home Lives in a nursing home Optional Lives in a residential home Optional Do you have any problems with housing Yes – Inadequate housing Optional No – Housing adequate Optional Housing difficulty: homelessness Homeless single person Optional Homeless family Optional Sofa surfer – person of no fixed abode Optional Lives in squat Optional Other Optional Please specify OptionalHousing rent – owned House rented from council Optional House rented from housing association Optional House rented from private landlord Optional Houseowner – no mortgage Optional Other Optional Please specify OptionalWould you like help with your housing? Yes Optional No Optional Employment and incomeEmployment status Unemployed Optional Employed Optional Retired Optional Student Optional Other Optional Do you have any problems at work? Yes Optional No Optional Do you have money problems that make it hard to meet your needs? Yes – Income insufficient to meet needs Optional No – Income sufficient to meet needs Optional Income difficulties Able to buy only necessities Optional Difficulty buying necessities Optional Low/no income Optional Would you like help with building skills, volunteering, or your job? Would like help with building skills, volunteering, or their job Optional Would not like help with building skills, volunteering, or their job Optional Would you like help with managing your money or benefits? Would like help managing money Optional Would not like help managing money Optional Would like help with benefits Optional Would not like help with benefits Optional Other factorsDo you feel lonely? Yes – Social isolation Optional No – Not socially isolated Optional Do you feel lonely and would like help to connect to local groups? Would like help to connect to local groups Optional Would not like help connecting to local groups Optional Please tick if you are a single parent Single parent Optional Do you have a social worker involved? Yes Optional No Optional Would you like help with smoking, exercise, or healthy eating? Yes No SignatureSignatureYour Full NameDate Day Month Year Comments OptionalThis field is for validation purposes and should be left unchanged.