Adult New Patient Questionnaire

Patient Details*

Name*

First NameLast Name

Previous Surnames/Maiden Name

Date of birth*

Date

NHS No (if known)

Gender*

MaleFemaleOther

Home Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Mobile Phone Number*

Home Phone Number*

Email Address*

example@example.com

Are you currently employed*

Full-TimePart-TimeSelf-EmployedUnemployed

Which best describes you*

RetiredStudentHousewife/Househusband/homemaker/other

Your first choice of contact*

LetterEmailTextPhone

Ethnicity*

What is your second language? (If applicable)

Do you need an Interpreter?*

YesNo

Please choose your religion*

NHS Regulations 2015 Self-Declaration*

I am a British resident and entitled to full NHS careI hold a non-UK issued European Health Insurance Card (EHIC)I hold an S1 form (entitled to health care in another European Economic Area country for a limited duration)

Next of kin full name*

First NameLast Name

Relationship to Patient*

Contact Phone Number*

Are you a carer for someone who is ill, frail, disabled, has substance problems or has mental health needs?*

YesNo

Do you have a carer?*

YesNo

Are you housebound*

YesNo

Do you need help with mobility/hearing/speaking?*

YesNo

Please help us trace your previous medical records by providing as much of the following information as possible:

Your previous address in the UK

Street Address

Street Address Line 2

CityCounty

Postcode

Name of previous Doctor while at the address

Address of previous doctors

Street Address

Street Address Line 2

CityCounty

Postcode

Address before enlisting

Street Address

Street Address Line 2

CityCounty

Postcode

Service or personnel number*

Enlistment Date

Date

Your first UK address where registered with a GP

Street Address

Street Address Line 2

CityCounty

Postcode

If previous resident in UK, Date of leaving

Date

Date you first came to livein UK

Date

Health Information

Height (CM)

Weight (KG)

About you and your families health

Do you have any allergies?*

YesNo

Have you or any of your family (borther/sisters,grandparents, aunts/uncles etc) had any of the following

What operations or serious injuries have you had?

Please list any mediationsor treatments you are undertaking, and for what condition?

Are you able to administer your own medicines?

YesNo

Please give details

Smoking

Do you smoke?

YesNoI used to

How many did/do you smoke per day?

What year did you start smoking?

Diet and Exercise

How would you describe your diet?

How much exercise do you do?

VigorousModerateGentleNo Exercise

How often doyou have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when drinking?

How often do you have 6 or more drinks in one occasion?

Further Information

Do you have a “Living Will” or “Advanced Directive”?

YesNo

Have you nominated someone to speak on your behalf?

YesNo

Contains details of your key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughout England. You will always be asked your permission before anybody look sat your Summary Care Record. Ask your GP about the optional “Additional Information” choice.

Please DO create me a Summary Care RecordPlease DO NOT create me a Summary Care Record

Allows your complete GP medical record to be made available to authorised healthcare professions involved in your care. You will always be asked your permission before anybody looks at your shared medical record.

I DO want to share my GP recordI DO NOT want to share my GP Record

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better. By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice.

If you are interested in getting involved in the PPG, please tick yes in the box below and we will contact you with further details.

Yes, I am interested in becoming involved in the PPGNo, I am not interested in becoming involved in the PPG

You can now book and cancel appointments, order repeat prescriptions, view your detailed medical records.

It will be your responsibility to keep your log in details and password safe and secure. If you know or suspect that your record has been accessed by someone else, please change your password immediately.

Yes, I would like to register for online servicesNo, I do not want to register for online services

Would you like to sign up for your prescription to be sent electronically to your pharmacy

YesNo

Name of nominated pharmacy

For more information, please ask for the leaflet on joining the NHS Organ Donor Register or visit www.organdonation.nhs.uk

I would like to join the NHS Organ Donor Register as someone whose organs may be used for translation after my death.

YesNo

Signature

Clear

Date

New Patient Registration Questionnaire(Adult: 16 Years old and over)

Next of Kin

Carers

Medical Records

If you are returning from armed forces

If you are from abroad

Summary Care Record

Medical Record Sharing

Patient Participation Group

Online Services

EPS (Electronic Prescription Service)

NHS Organ Donor Registration