New patient health questionnaire

Patient's details

First names(Required)

Surname(Required)

Previous surnames

NHS Number

Find your NHS number

Town and country of birth(Required)

Home address(Required)

Postcode(Required)

Home telephone(Required)

Enter NONE if you do not have one

Mobile number(Required)

Enter NONE if you do not have one

Please help us trace your previous medical records by providing the following information

Your previous address in UK(Required)

Please enter N/A if not applicable

Name of previous GP practice while at that address(Required)

Please enter N/A if not applicable

Address of previous GP practice while at that address(Required)

Please enter N/A if not applicable

Occupation/Job (current/past)(Required)

Please enter N/A if not applicable

If yes, please provide the name and contact details(Required)

Further information

Adult's mobile number(Required)

This is the Adult's mobile phone number. If the child is over 13 please provide the mobile number for the responsible adult here and the child's mobile in the box below (it is only visible if the correct age is selected above).

Child's mobile number(Required)

Next of Kin

Next of Kin full name(Required)

Relationship to you(Required)

Please enter N/A if not applicable

Next of Kin contact number(Required)

More about a child or newborn

Name of person with parental responsibility(Required)

Relationship to you(Required)

Name of GP surgery at which they are registered(Required)

Their current home address(Required)

Name and address of school/nursery attended(Required)

School/nursery phone number(Required)

Communication needs

What is your first language?(Required)

Please provide further information

Your lifestyle

What is your height?(Required)

What is your weight?(Required)

Smoking

How many per day?(Required)

When did you quit?(Required)

Alcohol

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption

Part Two Scores of 5 or more in Part 1 requires the following 7 questions to be completed

Score - part 2

0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

Medical information

Any other conditions, operations or hospital admission details:

Please list any immunisations or vaccinations you have had

Allergy details(Required)

Please provide further information(Required)

Please list below your current repeat medication(Required)

Please enter N/A if not taking any repeat medication

Pharmacy choice(Required)

We are a paper-free surgery, as such our prescriptions are all sent electronically to a pharmacy of your choice. Please let us know which pharmacy you would like prescriptions to be sent to (this can be changed at a future date).

Family history

Please give any details if you have ticked any of the above

Females only

Please give the dates of birth of your children(Required)

Please give the type and date of the hysterectomy(Required)

Please give the date when fitted(Required)

Looked after child/Child in care

A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.

If yes, please provide the name and contact details(Required)

Disability

You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.

If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)

Organ donation

In England it is considered that you agree to become an organ donor when you die if:

you are over 18;
you have not opted out;
you are not in an excluded group.

Find out more on www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

Patient Participation Group

Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.

New borns and under 5 immunisations

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

Surgery communication consent

Signature

You may be asked to sign this form when you visit the practice and provide ID and proof of address. If you were born outside of the UK, you may be required to bring your Passport and Visa with you.

Please enter your full name below(Required)

Patient's details

Please help us trace your previous medical records by providing the following information

Further information

Next of Kin

More about a child or newborn

Communication needs

Your lifestyle

Smoking

Alcohol

Alcohol consumption

Medical information

Family history

Females only

Looked after child/Child in care

Disability

Organ donation

Patient Participation Group

New borns and under 5 immunisations

Students only

Surgery communication consent

Signature

Policy

Helpful links