New Patient Questionnaire V2

You MUST fill in this questionnaire to complete your new patient registration. You WILL NOT be registered until this has been completed in full. This helps us find out more about your medical needs, and thus enables us to provide the required care and support you may need and improve the services we offer. This information is confidential and will NOT affect your registration. We would be grateful if you could make sure you complete the alcohol questionnaire at the bottom of the second page.

Last Updated: 18/06/2021

Your Contact Details

Information About You

Proof of Identity and Address Provided

Medical Information

This is about your past medical history and current medical needs



Please complete where appropriate



1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Family History

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Contacting You