New Patient Registration Questionnaire (BLOCK CAPITALS PLEASE)

Name:
	
Address:

Tel No: (Home)	
Tel No: (Mobile)	
Which number above is your preferred contact number?      Home/Mobile*   (*delete as appropriate)	
Date of Birth:	
Date of Registration	
Email address: 	
Please answer the following questions:

Do you smoke?	Yes	No	
If yes, how many a day		
If no, have you ever smoked	Yes	No	
If yes, how many a day		
Do you drink alcohol?	Yes	No	
If yes, on average, how many units do you drink each week?

(For reference – A standard glass of wine red/white/rose is 2.1 units, A pint of lower strength lager/beer/cider is 2 units & A single small shot of spirits is 1 unit)
	
Do you know your height? If so, please state			
Do you know your weight? If so, please state			
Are you on any medication?	Yes	No	
If yes, please give details:

	
Do you have a recent blood pressure reading? If so, please state		
Do you have a coil or implant fitted?	Yes	No	
If yes, when did you have it fitted?	

Do you have any allergies?	Yes	No	
If yes, please give details:

	
Are you a Carer?	Yes	No	
Do you have a carer?	Yes	No	
If yes give name and address and telephone number:

	

Next of Kin/Emergency Contact	
Name		
Address	

Telephone Number		
Relationship 		
Do you consent to your next of kin having access to your record?	Yes (if so, please sign below)	No	

Signed ________________________________________________

Do you have a preference to which Doctor you are registered with at this practice? If not, your registered Doctor will be Dr Featherstone, but you can still book an appointment to see any Doctor of your choice.	Yes	No	
If yes, please give details:

	
Have you ever served in the UK Armed Forces?

Please tick to indicate your ethnic group	
White		
Black Caribbean		
Black African		
Black, other, non-mixed origin		
Black – other, mixed		
Indian		
Pakistani		
Bangladeshi		
Chinese		
Vietnamese		
Other Black ethnic group		
Other Asian ethnic group		
Other ethnic group		

Do you need any form of communication support?  Please tick if you require any of the following when we communicate with you, or let us know if you have any other communication needs which are not listed here	
Large Print		
Sign Language		
Braille		
Email		
Other communication support

		

Text Messaging

If you are happy to receive text messages to remind you about appointments etc. please sign below to give your consent for this.
I give my consent to Stockwell Road Surgery to send me reminders via text message on the above number.

Signed ________________________________________

If you would like to order repeat prescriptions and book appointments online, please download the NHS app.