Mr / Mrs / Miss / Ms / Other……..
Address and Postcode
Next of Kin:
Next of Kin Contact Number:
Date of Birth:
Previous / Mother’s surname if different:
Town & Country of Birth
Other residents of your home:
Names & Ages of Children
NHS Number (If Known)
Previous Doctor Telephone No.
Previous Doctor Name & Address:
Previous data released?
If applicable, date you
first came to live in Britain :
If returning from
Your Service or Personnel Number
Your Enlistment Date
Feet / inches
Stones / lbs.
C of E
Other Christian (state)
Other religion (state)
Your Ethnic Origin:
White ( UK )
Brit Indian 9i7
Brit Pakistani 9i8
Bangladeshi / Brit Bangladeshi 9i9
not stated 9iG
Your main or 1st language Spoken / Understood:
Smoking, Alcohol Consumption and Exercise:
Are you currently a smoker?
Have you ever been a smoker?
If so, how many cigarettes / cigars / tobacco do you smoke in a week?
How much alcohol do you drink in a week (Units)?
(One unit = 1 small glass of wine, a single measure of spirits, or 1/2 a pint of beer)
If you are a smoker and want to stop, please ask for information about local smoking cessation services.
How often do you exercise?
No. times per week
Type(s) of exercise:
Your Medical Background:
What illnesses have you had & When?
What operations have you had and When?
Do you have any medical problems at present?
Please list any tablets, medicines or other treatments you are currently taking:
(incl. dose + frequency)
Are there any
serious diseases that affect your Parents, Brothers or Sisters
(tick all that apply)
Heart attack under age of 60
High Blood Pressure
Any other important Family Illness?
What immunisations have you had? (please tick all that apply)
Triple vaccine (Diphtheria,
Tetanus & Pertussis) –
Please detail below any specific needs you have so the Practice can ensure they are identified and accommodated by taking the appropriate action:
Please state any Sensory Impairment you have
(i.e. Speech, Hearing, Sight):
Are you an ‘Assistance Dog’ User?
Please state any Physical disabilities you have:
Please state any Mental disabilities you have:
Please state any requirements you have to be able to access the Practice premises
Please state any Religious or Cultural needs:
Do you require the help of a Translator / Interpreter?
Please state any specific nutritional requirements you have:
Please state any allergies and sensitivities you have:
Please state any phobias you have:
If you are a Carer, please state the name / address / phone number of the person you care for:
Person Cared For Contact Details:
If you have a Carer, please state their name / address / phone number and sign here if you wish us to disclose information about your health to your Carer.
Carer Contact Details:
Do you have a “Living Will”
(a statement explaining what medical treatment you would not want in the future)?
Yes / No
can you please bring a written copy of it
to your New Patient Consultation
Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)?
Yes / No
If “Yes”, please state their name / address / phone number:
When was your last smear done?
Was this at your
What was the result
of the smear?
Date of last mammogram
Method of contraception (if used):
Do you wish to see a doctor in this practice for contraceptive services (including the pill, coil or cap)?
Summary Care Records.
The NHS are changing the way your health information is stored and managed.
The NHS Summary Care record is an electronic record of important information about your health.
It will be available to health care staff providing your NHS Care. An information pack has been provided.
Are you happy to have a Summary Care Record?
More Time Required to decide:
Patient Participation Group
The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice.
If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation Group Application Form to be given to you at your initial consultation.
Yes, I am interested in becoming involved in the Practice Patient Participation Group (Please tick the “Yes” Box)
behalf of Patient: