New Patient Questionnaire V3

Updated 28th April 2022

Please answer as fully as possible. If you have any queries when completing this form please speak to a member of staff who will be happy to assist you. All information will be held in your personal health record and remains confidential.

Last Updated: 29/04/2022

Questionnaire date:

Date form completed: *

Your Contact Details

Title *

Name *

Date of Birth *

Address *

Postcode *

Home Number

Mobile Number

Email Address

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Other registered household members

Are any other members of your household registered with this Practice? *

Yes No

If 'YES', please give the name and date of birth so we can allocate you together

Information About You

We collect this information as it is directly relevant to your health care needs and is often required when a referral is needed.

Allergies

Do you have any allergies *

Yes No

If 'YES', please give details:

Are you allergic to any medication? (please state which ones)

Carers and Armed Forces

Do you have a carer? *

Yes No

If yes please give details (ie Name)

Are you a carer (unpaid, voluntary)? *

Yes No

If yes please give details of who you care for

If you are a carer (unpaid) would you like a referral to a carer agency who would be able to give you more information and advice? *

Yes No

Have you ever been a member of the Armed forces? *

Yes No

If yes, please state which service you served in

If yes, do you have any health issues related to your service - Please give details

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked?

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke each day?

Stopping smoking can make a big difference to your health. It is never too late to stop smoking to greatly benefit your health. Help is available if you want to stop smoking but are finding it difficult. Would you like advice on giving up smoking?

Yes No

Alcohol

1 unit = 1/2 pint beer/larger/cider

or 1 small glass of wine

or 1 single measure of spirits

On average, how many units of alcohol do you consume in a week? *

How often do you have a drink containaing alcohol? (can or bottle of beer, glass of wine, shot of hard liquor) *

How many units of alcohol do you drink on a typical day when you are drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Disabilities/Conditions

Do you have any disabilities or conditions that we can help you with when booking appointments? *

Yes No

If 'YES', please give details:

Do you struggle with hearing or understanding what the doctor or nurse may be telling you or accessing the information provided by the Practice? *

Yes No

Can we provide you with further help regarding accessing information or communication within the Practice because of issues with sight, hearing language or some other reason? *

Yes No

If 'YES', please give details below:

Patient Authority - Prescriptions

If you wish for someone else to collect your prescriptions on your behalf, you will have to provide the Surgery with written consent.

This consent will remain in force until further notice or cancellation by me.

Please complete the appropriate box: and leave the person's name or Pharmacy to send prescriptions to in the space below: *

Named person to collect prescription or Pharmacy where prescriptions are to be sent: *

Signature *

Date *

Contacting You/Leaving Messages

In accordance with the Data Protection Act, our Surgery requires written consent from any patient who has an answerphone and is happy for our staff to leave a message. If we do not have consent we will be unable to leave a message on an answerphone or with any third party (ie to notify a change or cancellation of an appointment).

If we do not have consent, we will be unable to send you a message or get in touch with a third party (unless it is thought to be a medical emergency)

Please complete the appropriate box *

Signature *

Date consent given *

Additional Information

Patient Participation Group

The Patient Participation Group are a committed group of patients, staff and members of the community, who work collectively as a voluntary group to support the Partners and Practice Manager in the effective runing of the Practice.

To sign up to receive a copy of our newsletter via email please visit the main website and click on the Practice Newsletter section at the bottom.

Summary Care Record

Summary Care Records are in operation in the NHS for each patient that will be used for emergency care. The record will contain information about any medication you are taking and any allergies or bad reactions to previous medications you have had, to ensure those caring for you have enough information to treat you safely. Please speak to a member of staff if you feel you need more general information or information on the opt out procedure.

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments.

In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used.

You can choose whether your patient information is used for research and planning. To find out more visit: nhs.uk/your-data-matters

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Borough Green Medical Practice website

New Patient Questionnaire V3

Please answer as fully as possible. If you have any queries when completing this form please speak to a member of staff who will be happy to assist you. All information will be held in your personal health record and remains confidential.

1 unit = 1/2 pint beer/larger/cider

or 1 small glass of wine

or 1 single measure of spirits

Patient Participation Group

The Patient Participation Group are a committed group of patients, staff and members of the community, who work collectively as a voluntary group to support the Partners and Practice Manager in the effective runing of the Practice.

To sign up to receive a copy of our newsletter via email please visit the main website and click on the Practice Newsletter section at the bottom.

Summary Care Record

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments.

In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used.

You can choose whether your patient information is used for research and planning. To find out more visit: nhs.uk/your-data-matters

Further Information