New Patient Questionnaire V3

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.

  • Questionnaire date:

    Date form completed:
    For example, 15 3 1984

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984

  • Next of Kin

  • Other registered household members

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

  • 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.

    Do you need an interpreter?
    Ethnic Group

  • Allergies

    Do you have any allergies

  • Carers and Armed Forces

    Do you have a carer?
    Are you a carer (unpaid, voluntary)?
    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?
    Have you ever been a member of the Armed forces?

  • Smoking

    Do you smoke?
    If 'No', have you ever smoked? (optional)
    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? (optional)

  • Alcohol

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

    or 1 small glass of wine

    or 1 single measure of spirits

  • Disabilities/Conditions

    Do you have any disabilities or conditions that we can help you with when booking appointments?
    Do you struggle with hearing or understanding what the doctor or nurse may be telling you or accessing the information provided by the Practice?
    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?

  • 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.

  • 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)

  • 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

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Page last reviewed: 29 April 2022
Page created: 09 May 2022