New Patient Questionnaire V2

Last Updated: 29/05/2020

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984
  • Information About You

    Do you need an interpreter?
    Ethnic Group
  • Previous GP

  • Proof of Identity and Address Provided

    Identity Document Type
  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    Are you registered disabled?
    Are you allergic to any medicines?
    Have you ever refused treatment/screening of any kind?
    Have you ever suffered from? (tick as appropriate) (optional)
    Do you have any other mental health issues?
  • Carers

    Do you have a carer?
    Are you a carer?
  • Women

    Have you ever had a cervical smear?
  • Will

    Do you hold a Living Will?
  • Smoking

    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking?
  • Alcohol

  • Family History

  • Next of Kin

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

  • 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.
  • Signature

    For example, 15 3 1984
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