New Patient Medical Questionnaire 2024

Last Updated: 17/07/2024

  • Your Contact Details

    Which of the following best describes what you/your child identify as?
    Martial Status (optional)
    HAVE YOU/YOUR CHILD BEEN REGISTERED WITH THE NHS BEFORE?
    Date of Birth
    For example, 15 3 1984

  • Information About You

    Do you need an interpreter?
    Ethnic Group
    ARMED FORCES (optional)

  • Previous GP

  • Proof of Identity and Address Provided

  • Medical Information

    Have you/your child ever suffered from? (tick as appropriate) (optional)
    Are you/your child registered disabled?
    Are you/your child allergic to any medicines?
    Do you have any allergies?

  • Electronic Prescriptions

  • Carers

    Do you have a carer?
    Are you a carer?

  • Women Only

    Have you ever had a cervical smear? (optional)
    Are you currently pregnant? (optional)

  • Will

    Do you hold a Living Will? (optional)

  • Smoking

    Do you smoke? (optional)
    Do you use an e-cigarette? (optional)
    If 'No', have you ever smoked? (optional)
    Would you like advice on giving up smoking? (optional)

  • Alcohol

  • Family History

  • Next of Kin

  • Blood and Organ Donation

    If you are interested in blood donation and would like to register as a blood donor? please visit https://www.blood.co.uk/
    If you are interested in organ donation and would like to register your decision then please visit: https://www.organdonation.nhs.uk/

  • Contacting You

    Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.
    Would you like to join our Patient Participation Group? (optional)

  • Signature

    Date
    For example, 15 3 1984
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