New Patient Questionnaire - 2023

Last Updated: 22/11/2023

Your Contact Details

Title

Occupation

Are you a Veteran?

Yes No

Do you consent to receiving text messages from the surgery? eg appointment reminders *

Yes No

Do you consent to receiving emails from the surgery eg. referral correspondence *

Yes No

Name *

Date of Birth *

Postcode *

Home Number *

Mobile Number *

Email Address *

Information About You

Previous GP

Proof of Identity and Address Provided

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Women

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Will

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Contacting You

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

Yes No

Signature

Signature *

Date *

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New Patient Questionnaire - 2023

Further Information