New Patient Questionnaire Form Over 16 Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number (if known) Optional First Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Female Male EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseTown* and Country of Birth *Please include borough if born in LondonAddress Street Address Address Line 2 City Postcode Main Contact NumberMobile Telephone Number OptionalHome Contact Number OptionalWe will use your mobile number to send appointment reminders and health promotion details. I do not wish to receive these messages OptionalEmail Enter Email Optional Confirm Email Optional How would you prefer us to contact you? Letter Optional Email Optional SMS (text) Optional Phone Optional Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Optional Address Line 2 Optional City Optional Postcode Optional Name of doctor while at that address Optional Address of previous doctor Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional If you are from abroadYour first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional If this is your first GP registration in the UK, please provide us the name of the country and date of arrival.Country Name Optional Date of Arrival Optional TB test Offered Yes Optional No Optional TB test accepted Yes Optional No Optional Armed ForcesPlease indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas: Regular Optional Reservist Optional Veteran Optional Family Member (Spouse, Civil Partner, Service Child) Optional Address before enlisting: OptionalService or Personnel number Optional Enlistment date Day Optional Month Optional Year Optional Discharge date (if applicable) Day Optional Month Optional Year Optional Please note that these questions are optional, and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority or service charities services.NHS Charges Regulations 2015 Self DeclarationI am a British Resident and entitled to full NHS Care Yes Optional No Optional I have paid the Immigration Health Surcharge (IHS) Yes Optional No Optional I hold a non-UK issued European Health Insurance Card (EHIC) (Complete details on reverse of GMS1 form) Yes Optional No Optional I hold a S1 form (entitlement to health care in another EEA country for a limited duration) Yes Optional No Optional DemographicsMarital Status Single, never married Married Civil Partnership Divorced Widowed Separated What is your main religion? No religion Optional Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional Buddhist Optional Hindu Optional Jewish Optional Muslim Optional Sikh Optional Other Optional Do you have access to secure housing? Yes No What is your current immigration status? Asylum Seeker Optional Failed Asylum Seeker Optional CarersDo you have caring responsibilities? None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say Do you have a carer? Yes No Carer’s Name First Last Relationship to you Address of carer Street Address Address Line 2 City Postcode Telephone number of carerNext of KinYour choice should be someone you feel close to. It does not have to be a blood relative or spouse. Before listing them on any medical documents, you should ask their permission and explain the role.Full Name Relationship to you Contact NumberDo you give us permission to discuss your medical records with them? Yes No Communication and Access NeedsDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language? Do you need an interpreter? Yes No DisabilityDo you have an impairment, health condition or learning difference that has a substantial or long-term (over a year) impact on your ability to carry out day-to-day activities? (Tick all that apply) No known impairment, health condition or learning difference Optional A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional A learning difficulty Optional Neuro-diverse e.g. dyslexia, dyspraxia or AD(H)D Optional Deaf or hearing impaired Optional Blind or have a visual impairment uncorrected by glasses Optional An impairment, health condition or learning difference that is not listed above Optional Prefer not to say Optional Do you have any specific mobility, information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalNo mobility, information and communication needsWalking aidHearing aidBritish sign language (BSL)Makaton sign languageLarge printBrailleOtherPlease stateAre you an ‘Assistance Dog’ User? Yes Optional No Optional Are you housebound? Yes Optional No Optional Health InformationHeight (in centimetres)Weight (in kilograms)Smoking Status Current Smoker Ex Smoker Never Smoked How many of the below do you smoke per day?Cigarettes per day Cigars per day Optional Grams of pipe tobacco per day Optional Are you interested in advice on how to quit? Yes No How would you describe your diet? OptionalHealthy (with meat)Unhealthy (with meat)Average (with meat)PescatarianVegetarianVeganPlease state how much exercise and what type of exercise you do per week OptionalVigorousModerateGentleNo ExerciseAlcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily Medical HistoryWhat operations or serious injuries have you had? OptionalHave you or anyone in your family (brother, sister, parents, grandparents, aunt, uncle) had any of the following? Cancer Optional Heart Attack under the age of 60 Optional Heart disease (under the age of 60) Optional Heart disease (over the age of 60) Optional High cholesterol Optional Stroke Optional Diabetes Optional Asthma Optional Thyroid disorder Optional COPD Optional High Blood Pressure Optional Hypertension Optional Depression Optional Bipolar or Schizophrenia Optional Chronic kidney disease Optional Emphysema Optional Other Optional Please specify If you answered yes to any of the above, please provide additional information.Women OnlyWhat is the date and result of your last Smear test? Date Optional Result Optional Was this at: GP Surgery Optional Other NHS Optional Private Optional Abroad Optional Date of last Mammogram (if applicable): Optional Current MedicationPlease list any medications or treatments you are undertaking and for what condition. OptionalAre you able to administer your own medicines? Yes No Please give details, e.g. swallowing or opening containers.AllergiesDo you have any allergies? Yes No Please provide more information.Please specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include datesFurther InformationDo you have a ‘Living Will’ or ‘Advanced Directive’? Yes Optional No Optional An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.Have you nominated someone who has Power of Attorney or been assigned a Personal Welfare Deputy? Yes Optional No Optional Online ServicesFor anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations. You will soon receive an email from the practice with your log in details.These are confidential: It is your responsibility to ensure they can be received securely by email. I do not want to be registered for online services OptionalSummary Care RecordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? Yes No Medical Record Sharing allows your complete GP medical record to be made available to authorised healthcare professionals involved in your care. You will always be asked your permission before anybody looks at your shared medical record.Do you want to share your GP record? Yes No Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year Comments OptionalThis field is for validation purposes and should be left unchanged.