New Patient Registration Form

Please complete the following form with as much information as you can. It is vital that you provide us with as much detail as possible.

Patient Details

Title
Surname
First Names
Previous Surname(s)
Date of Birth
Town/Country of Birth
Language Spoken
Occupation
Address
Post Code
Work Tel
Home Tel
Fax
Mobile Number
Your E-Mail
NHS Number Get this from your previous GP

Please help us trace your medical records

Prev. UK Address
Prev. GP Name
Prev GP Address

If you are from abroad

1st UK Address
Date of leaving UK (If previous resident)
Date of original arrival in UK

If you are returning from the armed forces

Address before enlisting
Service or personnel number
Enlistment Date

If you are registering a child under 5 years of age

 Yes I wish the child above to be registered with the doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

not all doctors are authorised to dispense medicines

 Yes I live more than 1 mile in a straight line from the nearest chemist.
 Yes I have serious difficulty getting to a chemist.

NHS Organ Donor Registration

I would like to join the NHS donor register as someone whose organs may be used for transplantation after my death. Please tick as appropriate.

Kidneys
Heart
Liver
Corneas
Lungs
Pancreas
Any part of my body

NHS Blood Donor Registration

 Yes I would like to join the NHS Blood Donor register as someone who may be contacted and would be prepared to donate blood.
 Yes Tick here if you have given blood on the last 3 years.

New Patient Questionnaire

Smoking

Do you smoke?  Yes No
If yes, state how many per day
What age did you start smoking?

Ex-Smokers

What age did you stop snoking?
How much did you smoke per day?

Passive Smokers

Are you exposed to passive smoking at work?  Yes No
Are you exposed to passive smoking at home?  Yes No

Alcohol

For the following questions please select the answer which best applies
1 drink = 1/2 pint of beer or one glass of wine or 1 single spirits

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?

Diet

Do you add salt to food after cooking?  No Yes
Do you have a varied diet including milk, meat, vegetables and fruit?  No Yes
Has your Cholesterol been checked in the last 5 years?  No Yes

Exercise

Do you take regular exercise?  No Yes
If yes, what sort?
How many times a week?

Family History

Is there any of the following in your family (father, mother, brother, sister)

Diabetes?  No Yes
Who?
Age?
Cancer  No Yes
Who?
Age?
Site?
Before the age of 65..
Heart Disease (Heart Attack/Angina)  No Yes
Who?
Age?
Stroke  No Yes
Who?
Age?

Medication

Please give details of any medication which you take (prescribed or otherwise):

Name of drug
Dosage
Name of drug
Dosage
Name of drug
Dosage
Name of drug
Dosage
Name of drug
Dosage

Allergies

Are you allergic to any substances or foods?  Yes No
If yes, please give details

Medical History

Diagnosed Current Conditions:

Please give details of any treatment for any current & chronic medical conditions:
Please give details of any hospital treatment as an in-patient:
Please give dates of any X-ray, MRI or CT scans, Mammogram, Ultrasound:

Female Patients

Date of most recent cervical smear
Result of smear
Please give details of any complications in pregnancy:

Carers

Do you need / have anyone who looks after you or your daily needs as Carer?
If “Yes”, would you like them to deal with your health affairs here?
(the receptionist can help with these arrangements)
Do you care for anyone else?
If “Yes”, ask the receptionist about Carers support

Thank you for completing this questionnaire. Please contact the surgery in 5 working days to arrange a new patient screening appointment with the HCA.

For Information on our opening times and availability of appointments please click here.