PATIENT REGISTRATION & HEALTH QUESTIONNAIRE.

(NB: all information supplied will be recorded in your confidential medical records)

Last Updated: 28/10/2024

Patients Details

Surname *

Forename(s) *

Title

NHS number (if known) *

Date of Birth *

Marital status

Previous surname

Known name (if different from above)

Mother's Maiden name *

Address *

Postcode *

Mobile *

Home tel

Email address

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccination reminders, to let you know that your prescription or your sick note is ready for collection and anything else relevant to your healthcare? *

Ethnicity

Gender

Language preference

English

Welsh

Other - please state below

Language

We have an electronic method of contact available for patients to contact the surgery for non urgent requests – do you consent for us to correspond with you via this method and supply us with a preferred e-mail address for this purpose?

Yes No

Previous address details

Address

Post code

Previous GP surgery

Previous GP Surgery Address

Post code

Name of previous doctor

Town / Country of birth *

First UK address where registered with a GP (if from abroad)

Have you ever registered with an NHS GP in the UK? (if from abroad)

Yes No

Date first coming to live in the UK.

Military Veteran

Have you ever served in the Armed Forces?

Yes No

Address before enlisting

Enlistment date

Date of discharge

Smoking

Current smoking status *

Quantity smoked per day

Past smoking details

Total time smoked (years)

User of electronic cigarette

Yes No

If having quit smoking, approximately how long has this been?

Smoking profile

Alcohol

For the following questions please answer to the best of your knowledge: We have provided a basic guide to alcohol content below to assist your completion:

A 750ml bottle of wine contains 10 units

A standard (175ml) glass of wine contains 2 units

A single small shot of spirits (25ml) contains 1 unit

A standard 70cl bottle of spirits contains 28 units

A pint of 3.6% strength lager/beer/cider contains 2 units

A pint of 5.2% strength lager/beer/cider contains 3 units

Follow the link below to access more information including a guide to calculating your alcohol intake - Alcohol units - NHS (www.nhs.uk)

Or you can use Alcohol Change’s calculator - Unit calculator | Alcohol Change UK

How many units of alcohol do you drink a week? *

Height & Weight

Please tell us your most recent measurements for the following (if known)

Height

Weight

Family History

Is there any of the following in your family (father, mother, brother, sister) before the age of 65?

Heart Disease? *

Yes No

Which family member?

Stroke? *

Yes No

Which family member?

Cancer? *

Yes No

Which family member?

Site of cancer?

Allergies

Do you have any allergies? *

Yes No

If Yes, please give details

Past Medical History

Please give details of any treatments/medical conditions: *

Carers

Do you need/have anyone who looks after you or your daily needs as Carer?

Yes No

If yes, please give details of the person who cares for you.

Do you care for someone else? (If Yes, please ask the reception staff about Carers support)

Yes No

Communication

Do you have any communication/information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?

Thank you for taking the time to complete this questionnaire.

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PATIENT REGISTRATION & HEALTH QUESTIONNAIRE.

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