New Patient Questionnaire V3

This questionnaire complements your application to register at Ashley Medical Practice. This is not an application form.

Last Updated: 18/02/2021

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Information About You

Proof of Identity and Address Provided

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Women

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Will

Do you hold a Living Will? *

Yes No

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 per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of 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? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

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

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

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

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. *

Yes No

Registration form

In order to complete your registration we require a registration form application as well as this Health Questionnaire

I confirm That I have submitted a Registration form as well. I understand that this form alone is not an application to register at Ashley Medical Practice. *

Yes No

Signature

Signature *

Date *

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New Patient Questionnaire V3

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