Dr Paul Evans MBBS MRCGP DRCO
Dr Duncan Wells MB ChB
Dr Rafia Hamid MB BS MRCGP DFFP DRCOG MCPS
NEW PATIENT REGISTRATION QUESTIONAIRE
An application will only be considered if supported by an original form of PHOTO ID (e.g. passport, driving licence)
and OFFICIAL proof of address dated within the last 3 months (e.g. utility bill)
and vaccination history for a child (ie. red book)
Current Visas MUST be shown for visitors from overseas.
Office use:………………………………………...
Viewed
By………………….
Date……………………
Surname………………………………………Title Mr/Mrs/Ms/Miss/Other………………First Name/s……………………………
Previous Surname (if applicable)………………………………Date of Birth………………… Place of Birth……………………
Address:………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………..Postcode:…………………………………………………………
Telephone:
Consent to leave a message
YES
NO
Home: ………………………………………………………………………
Mobile: ………………………………………………………………………
Work: ………………………………………………………………….
Email Address:……………………………………………………………………………………………….
Marital Status: Single/Married/Divorced/Separated/Widowed/Co-habiting/Civil Partnership/Other……………………
Are you a Carer? If YES please give details:………………………………………………………………………………………………………………..
Do you have a Carer? If YES please give details:………………………………………………………………………………………………………..
Ethnic Origin: Please indicate which is applicable to you. Some health problems are more common in specific communities,
as knowing your origins may help with the early identification of some of these conditions.
British/Mixed British
Irish
Other White Background
Indian/British
Polish
Japenese
White & Black Caribbean
White & Black African
Chinese
Bangladeshi/British
Other Asian
West Indian
Other Mixed Background
Country of Origin: ……………………………………………….Main Spoken Language…………………………………………………………
Do you require an interpreter for your appointment? YES/NO If YES which language:……………………………..
DJ 07/05/15
Height: ……………………………………………………… Cm
or ……………………………………………………..Ft/inches
Weight: ……………………………………………………… Kg
or ………………………………………………………St/Lbs
Smoking:
Current Smoker
Cigarettes
Alcohol:
Ex-Smoker
Cigars
Tobacco
Never Smoked
how many/how much you smoke per day……………...
Average units per week:……………………….
Beer: ½ pint = 1 unit
Allergies:
Spirits: single pub measure = 1 unit
Do you suffer from any allergies?
YES
Wine: 250ml of 12.5% = 3 units
NO
If YES please give details: ……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
Any medical history/information that may be relevant:……………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………
Do you have any Regular Repeat Medication YES / NO
If yes, then please provide us with the ‘repeat request side’ of your last issued prescription
and/or any relevant hospital letter
Do you have a nominated pharmacy YES / NO
Family History:
If so which one ……………………………………………….
Please indicate if any of the conditions below run in your immediate family
Epilepsy
d
Stroke/TIA (if under 60)
Diabetes
Coronary Heart Disease (if under 60)
High Blood Pressure
Glaucoma
Date of last Tetanus injection: ………………………………………
Date of last Cervical Smear: ………………………………………………Result if known: ……………………………………………..
I give consent for the surgery to speak to: …………………………………………………………………………………………….
Tel no: ……………………………………………………………………. On my behalf. (eg. Next of Kin/ Carer/Friend)
Summary Care Records
If you wish to have your details withheld from the ‘Summary Care Record’ please ask at
reception for the relevant ‘Opt Out’ information form
We will assume consent is implied unless you inform us otherwise.
DJ 07/05/15