New Patient Questionnaire

New Patient Questionnaire 28.10.20

Last Updated: 02/11/2020

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

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. *

Yes No

Do you have any specific communication needs?

Yes No

If yes, please give details

Information About You

Any prescriptions you request will be sent electronically to a pharmacy of your choice, please give us details:

Name and address of nominated pharmacy

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Please indicate what documents you are able to provide for Proof of Identity and Address (please send copies by email to pmg.contact@nhs.net)

Identity Document Type

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

Medical Information

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Women

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

Signature

Signature *

Date *

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New Patient Questionnaire

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