NEW PATIENT INFORMATION CARD
Surname ………………………………First name(s) ………………………………..
Full address…………………………………………………………………………….
…………………………………………………………Post Code …………………..
Tel No. home……………… Work …………………Mobile No…………………….
Sex ……. M / F
Date of birth ………………. Marital Status ……………………
Occupation……………………………………………………………………………
Have you been registered at this surgery before?
Yes 
No 
GENERAL HISTORY
Do you suffer for any of the following conditions? Please tick appropriate boxes
Diabetes 
Asthma  COPD  High Blood Pressure  Stroke 
Heart Disease 
Epilepsy 
Hypothyroidism  Mental illness 
What medicines are you taking? ……………………………………………………….
…………………………………………………………………………………………………………….
Have you any allergies to medicines or anything else?…………………………………
Smoking status –
never smoked 
ex-smoker  when did you stop?………
smoker  How many cigarettes / how much tobacco do/did you smoke? …….per day
Are you a carer? Do you look after someone close to you, who through reasons of
illness, disability, frailty, or an alcohol or drug problem, is unable to manage without
your help?
Yes 
No  If yes, please ask at reception for a questionnaire.
FAMILY HISTORY
please tick appropriate boxes
Which of your blood relations have suffered the following?
Heart Attack  …………………
Cancer  ……………………………..
Diabetes  ……………………….
Asthma  ………………………..
Stroke  ………………………….
High blood pressure ………………..
Tuberculosis  ………………………..
Other serious Illness  ……………….
FOR FEMALE PATIENTS ONLY
Have you had any children? 
give ages ………………………………
Have you had a termination of pregnancy?  give date ……………………………..
Have you had a hysterectomy? 
give date ……………………………..
What method of contraception are using at present? ………………………………….
When was your last smear? ……………………………………………………………
Please turn over
How much alcohol do you consume per week? (quantity in units)
Wine ………………… Beer ………………. Spirits ………………….
Questions
How often do you have a drink
Scoring system
Your
0
1
2
3
4
Never
Monthly or
2-4 times per
2-3 times
4+ times
less
month
per week
per week
1-2
3-4
5-6
7-8
10+
Never
Less than
Monthly
Weekly
Daily or
that contains alcohol?
Score
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?
monthly
almost
daily
Do you pay for your prescriptions?
 Yes
If yes, do you hold a pre-payment certificate?
DO NOT COMPLETE THIS SECTION
 No
Yes
 No
Date
Urine
Glucose
Albumin
BP
Weight
Height
Please turn over
PATIENT ETHNIC ORIGIN This follows the recommendations of the Commission for Racial Equality
and complies with the Race Relations Act.
Please indicate your ethnic origin and first language. This is not compulsory, but may
help with your healthcare, as some health problems are more common in specific
communities, and knowing your origins may help with the early identification of
some of these conditions.
Choose ONE section from A to E, and then tick ONE box to indicate your background.
A
White
British
Irish
Any other white background please state:
B
Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background please state:
C
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background please state:
D
Black or Black British
Caribbean
African
White and Asian
Any other black background please state:
E
Chinese or other ethnic group
Chinese
Any other please state:
Please turn over the page
Please turn over
First Language – please tick
001
003
005
007
009
011
013
015
017
019
021
023
025
027
029
031
033
035
037
039
041
043
045
048
050
052
054
056
058
060
Akan (Ashanti)
Amharic
Bengali 7 Sylheti
British Signing Language
Cantonese & Vietnamese
Dutch
Ethiopian
Finnish
French
Gaelic
Greek
Hakka
Hebrew
Igbo (Ibo)
Japanese
Kurdish
Luganda
Malayalam
Norwegian
Patois
Portuguese
Russian
Sinhala
Spanish
Swedish
Tagalog (Filipino)
Thai
Turkish
Vietnamese
Uoruba
002
004
006
008
010
012
014
016
018
020
022
024
026
028
030
032
034
036
038
040
042
044
046
049
051
053
055
057
059
200
Albanian
Arabic
Brawa & Somali
Cantonese
Creole
English
Farsi(Persian)
Flemish
French creole
German
Gujarati
Hausa
Hindi
Italian
Korean
Lingala
Makaton (sign language)
Mandarin
Pashto (Pushtoo)
Polish
Punjabi
Serbian/Croatian
Somali
Swahili
Sylheti
Tamil
Tigrinya
Urdu
Welsh
Other
I do not wish my ethnic origin or first language to be recorded 
Signature………………………………………………………………………..
Print Name ……………………………………………………………………..
Date ………………………………………………………………………………
Please turn over