New Patient Registration/Health Questionnaire

Gender

Marital status

Ethnicity

Home phone number

Work phone number

Mobile number (if aged 16 or over)

Language preference

English
Welsh
Other

If Other, please specify

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccinations reminders 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 email address for this purpose?

Yes

No

Email address

Yes

No

Do you smoke?

Yes
No
Ex-smoker

If yes, how many (Cigarettes per day, ounces of tobacco per day, Electronic cigarettes)

If ex-smoker, what date did you stop smoking?

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?

Height

Weight

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

Name

Relation

Contact number

The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?

Heart Disease?

Yes

No

Stroke?

Yes

No

Cancer?

Yes

No

Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.

Yes

No

Name of drug - Dosage

Please add a photo of 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 a Carer?

Yes

No

If Yes, would you like them to deal with your health affairs here?

Yes

No

Do you care for anyone else?

Yes

No

Have you been registered here previously?

Yes

No

Have you moved to the UK from abroad?

Yes

No

Please tick any/all that apply.

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?

Meddygfa Minafon

New Patient Registration/Health Questionnaire

Contact Details

Smoking

Alcohol

Height & Weight - Please tell us your most recent measurements for the following (if known).

Next of Kin

Family History

Medication

Allergies

Past Medical History

Carer Information

History

Special Circumstances

Military Veteran

Communication