New Patient Registration Form

Today’s Date:

Please complete this confidential questionnaire (one for each member of the family to be registered with the Practice).

Please complete in BLOCK CAPITALS and tick the boxes as appropriate.

If you are newly arrived in this country, please bring your passport to confirm your date of birth and entitlement to NHS treatment.

Please complete a separate form for each family member to be registered.

Full Name:

Telephone Number:

Mr / Mrs / Miss / Ms / Other……..

Work Number

Address and Postcode

Mobile Number:

E-mail Address:

Next of Kin:

Next of Kin Contact Number:

Date of Birth:

Previous / Mother’s surname if different:

Town & Country of Birth

Marital Status:

Gender:

Male:

Female:

Other residents of your home:

Occupation:

Names & Ages of Children

Housing

(Select one)

House

Maisonette

Flat

Mobile Home

NHS Number (If Known)

Previous Address

Previous Postcode:

Previous Doctor Telephone No.

Previous Doctor Name & Address:

Previous data released?

Yes

If applicable, date you

first came to live in Britain :

If returning from

Armed Forces:

Your Service or Personnel Number

Your Enlistment Date

Your

height:

Feet / inches

Your

weight:

Stones / lbs.

Your

Religion:

C of E

Catholic

Other Christian (state)

Buddhist

Hindu

Muslim

Sikh

Jewish

Jehovah’s Witness

No religion

Other religion (state)

Your Ethnic Origin:

(select one)

White ( UK )

9i0

White (Irish)

9i1%

White (Other)

9i2%

Caribbean

9i3

African

9i4

Asian 9i5

Other Mixed

Background 9i6%

Indian /

Brit Indian 9i7

Pakistani /

Brit Pakistani 9i8

Bangladeshi / Brit Bangladeshi 9i9

Other Asian

Background 9iA%

Other Black

Background

Chinese

9iE

Other

9iF%

Ethnic Category

not stated 9iG

Your main or 1^st language Spoken / Understood:

(select one)

English

Hindi

Gujurati

Urdu

Bengali /Sytheti

Punjabi

Polish

Ukrainian

French

German

Spanish

Other:

(Please

Specify)

Smoking, Alcohol Consumption and Exercise:

Are you currently a smoker?

Yes

Have you ever been a smoker?

Yes

If so, how many cigarettes / cigars / tobacco do you smoke in a week?

How much alcohol do you drink in a week (Units)?

(One unit = 1 small glass of wine, a single measure of spirits, or 1/2 a pint of beer)

If you are a smoker and want to stop, please ask for information about local smoking cessation services.

How often do you exercise?

No. times per week

Type(s) of exercise:

Your Medical Background:

What illnesses have you had & When?

What operations have you had and When?

Do you have any medical problems at present?

Please list any tablets, medicines or other treatments you are currently taking:

(incl. dose + frequency)

Are there any

serious diseases that affect your Parents, Brothers or Sisters

(tick all that apply)

Diabetes

Heart Attack

Heart attack under age of 60

Bowel Cancer

Breast Cancer

High Blood Pressure

Asthma

Stroke

Thyroid Disorder

Any other important Family Illness?

What immunisations have you had? (please tick all that apply)

Diphtheria

Measles

German Measles

Tetanus

Polio

MMR

Whooping Cough

Pre-school booster

Triple vaccine (Diphtheria,

Tetanus & Pertussis) –

3 doses

Specific Needs:

Please detail below any specific needs you have so the Practice can ensure they are identified and accommodated by taking the appropriate action:

Please state any Sensory Impairment you have

(i.e. Speech, Hearing, Sight):

Are you an ‘Assistance Dog’ User?

Please state any Physical disabilities you have:

Please state any Mental disabilities you have:

Please state any requirements you have to be able to access the Practice premises

Please state any Religious or Cultural needs:

Do you require the help of a Translator / Interpreter?

Please state any specific nutritional requirements you have:

Please state any allergies and sensitivities you have:

Please state any phobias you have:

If you are a Carer, please state the name / address / phone number of the person you care for:

Person Cared For Contact Details:

If you have a Carer, please state their name / address / phone number and sign here if you wish us to disclose information about your health to your Carer.

Carer Contact Details:

Signed: Date:

Do you have a “Living Will”

(a statement explaining what medical treatment you would not want in the future)?

Yes / No

If “Yes”,

can you please bring a written copy of it

to your New Patient Consultation

Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)?

Yes / No

If “Yes”, please state their name / address / phone number:

Women only:

When was your last smear done?

Date

Was this at your

GP’s Surgery?

Yes

What was the result

of the smear?

Date of last mammogram

(if applicable):

Date

Method of contraception (if used):

Do you wish to see a doctor in this practice for contraceptive services (including the pill, coil or cap)?

Yes

Summary Care Records.

The NHS are changing the way your health information is stored and managed.

The NHS Summary Care record is an electronic record of important information about your health.

It will be available to health care staff providing your NHS Care. An information pack has been provided.

Are you happy to have a Summary Care Record?

Yes

More Time Required to decide:

Patient Participation Group

The Practice is committed to improving the services we provide to our patients.

To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.

By expressing your interest, you will be helping us to plan ways of involving patients that suit you.

It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice.

If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation Group Application Form to be given to you at your initial consultation.

Yes, I am interested in becoming involved in the Practice Patient Participation Group (Please tick the “Yes” Box)

Yes

Patient

Signature:

Signature on

behalf of Patient:

NHS ORGAN DONOR REGISTRATION

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Any of my organs □

Kidneys □ Heart □ Liver □ Corneas □ Lungs □ Pancreas □