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















Carers






FOR WOMEN ONLY

Please complete where appropriate





Smoking








Alcohol

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


Signature