New Patient Registration

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New Patient Health Questionnaire

Welcome to Elsdale Street Surgery. Thank you for taking the time to register with us. In order for us to get to know our new patients and to help us offer you the right services, we ask that you fill in this simple questionnaire. We will treat the information that you provide in the strictest of confidence and in accordance with legislation. Following on from the questionnaire, an appointment will be made for you to see one of our nurses who will complete a couple of routine checks which will provide us with an opportunity to get to know you better. More information about this is found in the ‘New Patient Information’ leaflet. If you have any questions, or are not quite sure of how to answer these questions, one of our Receptionists will only be too happy to help.

Personal Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Title: *

Gender: *

Is English your first language?: *

Do you require a translator?: *

Ethnicity & Religion

Please specify the ethnic group you consider you belong to: *

Your Religion:

Previous Details

Please include postcode

Are you registering for the first time in the UK? : *

Are you returning from abroad?: *

If you are from abroad

Please use this date format: DD/MM/YYYY

Refugee: *

Asylum Seeker: *

Do you require an interpreter when you see the doctor/nurse?: *

Are you returning from abroad? : *

If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY

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Medical History

You can use the practice facilities.

Do you have or think you have/had any of the following?:

Smoking Status: *

Are you interested in advice on how to quit?: *

Family History

Have / are any of your family members (been) affected by:

Does anyone in your family have a chronic / long-term illness?:

Do you care for children under the age of 18?:

Your Personal Alcohol Consumption

How often did you have a drink containing alcohol in the past year?:

How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?: *

How often did you have six or more drinks on one occasion in the past year?: *

Allergies

Do you have any allergies?: *

Immunisation History

Have you received all your childhood immunisations?:

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Have you had the BCG (Tuberculosis) vaccine?:

Have you travelled abroad in the past 5 years?:

Did you receive travel vaccines?:

Women's Health

Have you had a smear in the last 3 years?:

Are you currently pregnant?:

HIV Test

Do you want a HIV test?:

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Registration

New Patient Health Questionnaire

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