New Patient Questionnaire

This questionnaire is to be completed for every person registering with our Practice. Please answer ALL questions (where applicable) to avoid any delay in the registration process.

Last Updated: 04/03/2024

Your Personal Details

Title *

Forename *

Surname *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Telephone Number

Mobile Telephone Number *

Email Address *

NHS Number *

Next of Kin Details

Title *

Forename *

Surname *

Relationship to you *

Telephone Number *

Information About You

Do you have any communication needs? *

Yes No

If yes, please give details

What is your first language? *

Do you need an interpreter? *

Yes No

Are you a Carer? *

Yes No

If yes, please give details

Are you registered disabled? *

Yes No

If yes, please give details

Social Details - Please complete for Patients aged 12 and over only:

What is your height?

What is your weight?

Do you smoke?

Yes No

If yes, how many do you smoke per day?

Have you ever smoked?

Yes No

If yes, when did you stop and how many did you smoke per day?

Do you drink alcohol?

Yes No

If yes, how many units per day?

Family History - Please complete for Patients aged 12 and over only:

Please let us know if you have any Family History of the following conditions:

Consent for Immunisations - Please complete for Patients under 16 only

I consent to my child being vaccinated as per the National guidelines

Yes No

Relationship to Child

Signature (Please note your printed name will be taken as your signature)

Contacting You

Do you agree to being contacted by the surgery, via email and/or SMS, with advice about your health, appointment reminders, or Practice news. *

Yes No

Would you like to be added to our Patient Participation Group (PPG) mailing list for information about health events or surgery news? *

Yes No

Signature

Signature (Please note your printed name will be taken as your signature) *

Date *

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