New patient registration

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    Patient details

    Previous Details

    Please help us trace your previous medical records by providing the following information


    Next of kin

    Permission to use your details

    Do you consent to the practice contacting you by text or email message for the purposes of health promotion and for appointment reminders?

    Are you interested in joining our patient participation group?

    This group meets every 2 months to allow patients to have a say in how we can provide the best care for them.

    Do you consent to us sharing your email address with the chair of the patient participation group so that she can provide you with further details?

    Do you consent to share your medical records with authorised healthcare staff like emergency departments so that they are better equipped to treat you safely and effectively?

    Do you consent for this practice to view medical information that you've agreed to share at other NHS care services?

    Gender and sexual orientation

    What is your sexual orientation?

    Which of the following best describes you?

    Is your gender identity the same as the gender you were given at birth?

    Measurements

    Smoking

    Do you smoke?

    Are you interested in our stop smoking clinic?

    Are there any smokers in the household?

    Exercise

    In an average week how often do you exercise?

    Note: twenty minutes of vigorous walking counts as one exercise session.

    Armed forces

    Have you ever been in the armed forces?

    Alcohol

    How often do you have a drink that contains alcohol?

    How many standard alcoholic drinks do you have on a typical day when you are drinking?

    How often do you have 6 or more standard drinks on one occasion?

    How often in the last year have you found you were not able to stop drinking?

    How often in the last year have you failed to do what was expected of you because of drinking?

    How often in the last year have you needed an alcoholic drink in the morning to get you going?

    How often in the last year have you had a feeling of guilt or regret after drinking?

    How often in the last year have you not been able to remember what happened when drinking the night before?

    Have you or someone else been injured as a result of your drinking?

    Has a relative or friend or a doctor or another health worker been concerned about your drinking or advised you to cut down?

    Further support for alcohol dependence is available from the surgery or from our local alcohol service Change Grow Live (Tel: 01274 296023)

    Medical information

    Have you suffered from any of the following?

    Epilepsy

    High blood pressure

    Heart attack / angina

    Stroke

    Kidney disease

    Cancer

    Diabetes

    Asthma / breathing problems

    COPD

    Thyroid problems

    Mental health problem

    Dementia

    Do you have a pacemaker?

    Are you under the care of a hospital specialist at present?

    Are you currently pregnant?

    Medication

    Do you have any allergies or reactions?

    (e.g. to eggs, medicines, vaccinations, medical dressings or foodstuffs)

    Nominated pharmacy

    Would you like to nominate a local pharmacy where we can send your prescriptions?

    Carers

    Do you have a carer?

    Do you give permission for us to discuss your medical needs with your carer?

    Are you an unpaid carer?

    If yes, who do you care for?

    Language requirements

    Do you require an interpreter?

    Disabilities and other needs

    It is important for us to identify and log a patient’s requirements in their medical notes if they have a recorded disability.

    Blind

    Partially sighted

    Deaf

    Deaf / blind

    Learning disability

    Visual impairment

    Hearing difficulties

    Use of hearing aids

    Ethnic group information

    This practice, in line with other healthcare providers, collects information about the ethnic group that patients feel they belong to. You do not have to complete this form but if you do you will be helping us to help you. It will help us plan to deliver better services to our patients and ensure that everyone has equal access to the health care we provide.

    All the information that we receive will be used and treated with the strictest confidence in the same way as other information that we hold. When used in the planning of services all names and other identifying details will be removed.

    Providing the following information is optional.

    Ethnicity