New Patient Registration/Health Questionnaire

Surname

Forename(s)

NHS Number (if known)

Date of Birth

Marital Status

Address

Postcode

Home telephone number

Mobile (if aged 16 and over)

Ethnicity

Gender

Language Preference

English
Welsh

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccination reminders, to let you know that your prescription or your sick note is ready for collection and anything else relevant to your healthcare?

Yes

No

We have an electronic method of contact available for patients to contact the surgery for non-urgent requests – do you consent for us to correspond with you via this method and supply us with a preferred e-mail address for this purpose?

Yes

No

What is your email address?

Do you smoke?

Yes
Never smoked
Ex Smoker

If yes, how many cigarettes / ounces per day?

Do you vape

Yes
No
Never vaped
Ex Vaper

For the following questions please answer to the best of your knowledge: We have provided a basic guide to alcohol content below to assist your completion:

A 750ml bottle of wine contains 10 units.

A standard (175ml) glass of wine contains 2 units.

A single small shot of spirits (25ml) contains 1 unit.

A standard 70cl bottle of spirits contains 28 units.

A pint of 3.6% strength lager/beer/cider contains 2 units.

A pint of 5.2% strength lager/beer/cider contains 3 units.

How many units of alcohol do you drink a week?

Please tell us your most recent measurements for the following (if known)

Height

Weight

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

Is there any of the following in your family (father, mother, brother, sister) before the age of 65?

Heart Disease?

Yes

No

If yes, which family member?

Stroke?

Yes

No

If yes, which family member?

Cancer?

Yes

No

If yes, which family member?

Please give details of any medication which you take (prescribed or otherwise). Please include name of drug and dosage

Please attach or forward us your most recent repeat medication slip if you have one.

Do you have any allergies?

Yes

No

If yes, please give details

Please give details of any treatments/medical conditions:

Do you need/have anyone who looks after you or your daily needs as Carer?

Yes

No

If yes, would you like them to deal with your health affairs here? A member of reception staff can help with these arrangements)

Yes

No

Do you care for anyone else? (If yes, please ask the reception staff about Carers support)

Yes

No

Have you ever served in the Armed Forces?

Yes

No

Do you have any communication/information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?

Riverside Medical Practice

New Patient Registration/Health Questionnaire

Smoking/Vaping

Alcohol

Height and Weight

NB: The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records.

Family History

Medication

Allergies

Past Medical History

Carers

Military Veteran

Communication