New Patient Questionnaire (ADULT)

Please ensure this form is filled in fully 

Last Updated: 25/03/2024

  • Patient Details

  • Smoking Satus

    Have you ever smoked?
    If yes, but ex-smoker, when did you stop? (optional)
    For example, 15 3 1984
    Do you smoke at present?
    Would you like to give up smoking? (optional)
    Would you like help and assistance in stopping smoking? (optional)

  • Height and Weight

  • Alcohol Intake

    Do you drink alcohol?

  • Allergies

    Do you have any allergies?

  • Summary Care Record

    Summary Care Records are electronic records of important information created from GP medical records. They can be seen and used by authorised staff in other areas of health and care systems involved in patients direct care

     
    Are you happy to have a summary care record created? If no please ask the Reception team for an 'opt out' forrmm

  • Medication

  • Armed Forces

    Are you returning from the Armed Forces or a Military Veteran?
    Do you consent to this information being coded onto your medical record? (optional)

  • Sexual Orientation

  • Gender and Trans Status

    Is your gender identity the same as the gender you were given at birth? (optional)

  • Ethnic Group

  • CARER

    If you are a carer please complete the following section. The carers advocate at the practice will contact you to help signpost you to appropriate services that are available 

    Do you care for somebody? (optional)
    Are they registered with this practice? (optional)
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