SUMMERTOWN HEALTH CENTRE
160 Banbury Road, Oxford, OX2 7BS www.summertownhealthcentre.co.uk
Tel: 01865 515552 Fax 01865 311237
For surgery use only
Rec’d by ____________
EMIS no _____________
NEW PATIENT REGISTRATION QUESTIONNAIRE – PART 1
to be completed by all patients over the age of 12
Reg by _______________
This information will help us to provide you with the best care until your full medical records are received. Please
hand it to the receptionist when completed.
Title and Last Name
Male

ALL Forenames
Female

Date of Birth
Address
We may wish to contact you to discuss your health or to text you reminders about your appointments.
Confidentiality is very important to us so if you do not wish us to contact you via text or email please
tick the boxes below.
UK Mobile number________________________________________
Please tick this box if you do not want to receive text messages from the surgery.
Email address____________________________________________
Please tick this box if you do not want to receive emails from the surgery.
Home telephone number: __________________________________
Work Tel No:
Are you a student?
Occupation:
Yes

No

Do you have significant (unpaid) caring responsibility for
someone?
If yes, at which college?
Yes

No

MEDICAL HISTORY
Have you ever suffered from? (tick as appropriate)
Date diagnosed
Epilepsy
High Blood Pressure
Heart Attack/Stroke
Cancer
Eczema/Hay Fever
Blindness/Glaucoma
Hyperthyroidism
Chronic kidney disease
Date
Date
Date
Date
Date
Date
Date
Date
Are you currently under medical care of any sort?
If yes, please describe
Diabetes
Depression
Mental Health Problems
Asthma
COPD
Hysterectomy
Other (please give details):
Yes  No 
Date diagnosed
Date
Date
Date
Date
Date
Date
Do you suffer from any allergies?
If yes, please describe
Are you taking any regular medication?
If yes, please describe
Yes  No 
Yes  No 
Do heart attacks and strokes tend to occur in young members of your family (less than 55 years old)? Yes  No 
Give details of any illness which tends to occur in your family.
Yes  No 
Has anyone under 55 in your near family suffered from diabetes?
What is your present weight?
Do you smoke?
Yes 
_________________
No  Never Smoked 
How tall are you?
___________________
Ex-smoker  Date stopped _________________
If yes, would you like help to stop?
Yes 
No 
Would you like free Chlamydia Screening
(The kits can be obtained from one of the surgery toilets)
Yes 
Declined
Have you had a cervical smear test?
Details of smear testing:
Yes 
No 
Do you drink alcohol?
Yes 

No 
If your score is more than 5 please complete the AUDIT questionnaire (last page)
Please answer each question by circling the boxes that are most appropriate.
Physical activity at
unemployed
Mostly sitting
Mostly standing
Involves definite Involves vigorous
work
or walking
physical activity
physical activity
Physical hours
None
1 hour
3 hours
More than
exercise in the last
3 hours
week
Hours in the last week None
1 hour
3 hours
More than 3
spent cycling
hours
Hours in the last week None
1 hour
3 hours
More than 3
spent walking
hours
Hours in the last week None
1 hour
3 hours
More than 3
spent on
hours
housework/child care
Hours in the last week None
1 hour
3 hours
More than 3
spent gardening
hours
Usual level of walking Slow
Steady
Brisk
Fast
pace
Summary Care Record (SCR)
Please see the information attached about the Summary Care Record and the Oxfordshire Care
Summary. If you want to be included in these, please tick and sign below. If you wish to opt out,
please fill in the separate opt out form.
I want my records to be included in the Summary Care Record.
I want my records to be included in the Oxfordshire Care Summary.
Signed _____________________________________________ Date ___________________________
ETHNIC GROUP DATA COLLECTION - STRICTLY CONFIDENTIAL
The Health Service needs to know the ethnic group of patients for the purpose of planning. This is to make sure that
all sectors of the community have equal access to the services provided. Ethnic group describes how you see yourself,
and is a mixture of culture, religion, skin colour, language, the origins of yourself or your family. It is not the same
as nationality. The information given will be treated in the strictest confidence.
The information is used only by National Health Service Staff and will not be passed on to other agencies, or used for
any other purposes.
White – British
White – Irish
Mixed – White and
Asian
Any other mixed
background
Any other Asian
background
Indian
Black – Caribbean
Questions
Mixed – White and
Black African
Pakistani
Bangladeshi
Any other Black
background
Black – African
Any other Ethnic Group
Is your first language English?
Mixed – White and
Black Caribbean
Any other White
Chinese
Do not want to give Ethnic Group
Yes
No
If no, please specify _____________________________
AUDIT - Only to be completed if you scored more than 5 on the AUDIT C
Scoring System
0
1
2
3
4
How often do you have a drink that
contains alcohol?
How many standard alcoholic drinks
do you have on a typical day when
you are drinking?
How often do you have 6 or more
standard drinks on one occasion?
How often in the last year have you
found you were not able to stop
drinking once you had started?
How often in the last year have you
failed to do what was expected of you
because of drinking?
How often in the last year have you
needed an alcoholic drink in the
morning to get you going?
How often in the last year have you
had a feeling of guilt or regret after
drinking?
How often in the last year have you
not been able to remember what
happened when drinking the night
before?
Have you or someone else been
injured as a result of your drinking?
Has a relative/friend/doctor/health
worker been concerned about your
drinking or advised you to cut down?
Never
Monthly or
less
2 – 4 times
per month
2 – 3 times
per week
4+ times per
week
1-2
3-4
5-6
7-8
10+
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
No
No
Yes, but not
in the last
year
Yes, but not
in the last
year
Your
Score
Yes, during
the last year
Yes, during
the last year
Scoring: 0-7 = sensible drinking, 8-15 = hazardous drinking, 16-19 = harmful drinking and 20+ =
possible dependence.