New Patient Questionnaire

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984

  • Information About You

    Do you need an interpreter?
    Ethnic Group

  • Previous GP

  • Proof of Identity and Address Provided

    Identity Document Type

  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    Are you registered disabled?
    Are you allergic to any medicines?
    Have you ever refused treatment/screening of any kind?
    Have you ever suffered from? (tick as appropriate) (optional)
    Do you have any other mental health issues?

  • Carers

    Do you have a carer?
    Are you a carer?

  • Women

    Have you ever had a cervical smear?

  • Will

    Do you hold a Living Will?

  • Smoking

    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking?

  • Alcohol

  • Family History

  • Next of Kin

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

  • 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.

  • Signature

    Date
    For example, 15 3 1984
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 23 October 2019
Page created: 02 October 2026