HEALTH QUESTIONNAIRE

Health questionnaire for Newly Registered Patients

Personal Details

Which ethnic group do you belong to:

Which ethnic group do you belong to:

Are you from abroad?

Are you from abroad?

Are you returning from the army?

Are you returning from the army?

Have you been a patient at the Surgery before?

Health Questionnaire

Have you been a patient at the Surgery before?

Smoking habits?

Smoking habits?

Would you like support to quit smoking?

Would you like support to quit smoking?

Do you have any of the following diseases?

Do you have any of the following diseases?

Are you on current medication (repeat)?

Are you on current medication (repeat)?

You need to book in for a medication review with your registered GP before we can reissue.

Are you a full time carer for a dependant person?

Are you a full time carer for a dependant person?

Do you have a carer?

Do you have a carer?

How did you hear about us?

How did you hear about us?

Are you aware of what a Summary Care Record is and that you will be automatically enrolled unless you opt out?

Are you aware of what a Summary Care Record is and that you will be automatically enrolled unless you opt out?

Would you like PatientAccess to enable you to book appointments, order prescriptions and view your medication and allergies history online? If yes please register via our home page link.

Would you like PatientAccess to enable you to book appointments, order prescriptions and view your medication and allergies history online? If yes please register via our home page link.

Send Your Request

By clicking the Submit button below I confirm that I am an ordinary resident at an address within the practice area and that I am legally entitled to register with an NHS GP.

Thank you for registering with us online. Your form will be actioned with 48 hours. Before you are able to use our services we must see you in person with id that includes your current address on it. For example photo driving licence or passport accompanied with a utility bill.

Thank you! Your submission has been received!

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Patient UK

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