PATIENT REGISTRATION/HEALTH QUESTIONNAIRE V3

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 (if aged 16 and over)

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?

Home tel

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

Email address

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

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

PATIENT REGISTRATION/HEALTH QUESTIONNAIRE.

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PATIENT REGISTRATION/HEALTH QUESTIONNAIRE.

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