New patient health questionnaire (adults)

You MUST complete this form as well as the registration form or we can’t register you.

Step 1 of 5

20%

Your Contact Details

Title

Name(Required)

First Names Surname

Previous Surnames

Date of Birth(Required)

Day

Month

Year

NHS Number(Required)

Get help to find your NHS number online

Home Address (inc. flat number if appropriate)(Required)

Postcode(Required)

Home Telephone(Required)

Mobile Telephone

Email address(Required)

Enter Email Confirm Email

Occupation

Information About You

What is your height?(Required)

What is your weight?(Required)

What is your first language?(Required)

Do you need an interpreter?(Required)

Yes

Ethnicity(Required)

White British

White Irish

Black Carribbean

Black African

Asian Indian

Asian Pakistani

Asian Chinese

White + Black Carribbean

White + Black African

White + Asian

Prefer not to say

Other

Previous GP

Name and Address of Previous GP

Patient Nominated Pharmacy

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use

Please give the name and address of the pharmacy

Proof of Identity and Address Provided

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Medical Information

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place.

Have you ever suffered from? (tick as appropriate)

Epilepsy

Yes

High Blood Pressure

Yes

Heart Attack/Stroke

Yes

Cancer

Yes

Eczema/Hay Fever

Yes

Blindness/Glaucoma

Yes

Diabetes

Yes

COPD

Yes

Depression

Yes

Asthma

Yes

If yes, please state the year(s) when were you first diagnosed

Please list any medicines being taken and the amount:

Are you registered disabled? (If yes, please give details)

Yes

Details of my disability

Are you allergic to any medicines and if so, which?

Yes

Details of my allergy

Have you ever refused treatment/screening of any kind and if so, what and when?

Yes

Details of my screening/treatment refusal

Medical Information (continued)

Have you ever suffered from? (tick as appropriate)

Anxiety

Yes

OCD

Yes

Depression

Yes

Bipolar Disorder

Yes

If yes to any of these, please state the year(s) when were you first diagnosed.

Do you have any other mental health issues? (If yes please give details).

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it).

Carers

Do you have a carer? (If yes please give details)

Yes

My carers details

Are you a carer? (If yes please give details)

Yes

I am a carer for...

Will

Do you hold a Living Will?

Yes

(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

Women

Have you ever had a cervical smear?(If 'yes', please state when, where and the result).

Yes

Where, when and the result of the smear test

Smoking

Do you smoke?

Yes

If 'No', have you ever smoked?

Yes

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes

Alcohol

1 drink = 1/2 pint of beer OR 1 glass of wine OR 1 single spirit

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Next of Kin

Please give name, address, telephone number and relationship of next of kin.

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? If yes, please specify the date.

Have you had a pneumococcal vaccination? If yes, please specify the date.

Contacting You

Please consent to being contacted

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Signature

Date and signature

(you will be asked to sign this form when you visit the practice)

Consent(Required)

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 30 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.

I agree to the privacy policy.