Services

New Patient Online Questionnaire

Complete our new patient online questionnaire to ensure we provide you with the best possible care.

New Patient Health Questionnaire

Please complete this confidential questionnaire (one for each member of the family to be registered).

Please only fill out the questions that apply to you, if the question is not relevant please click 'Next Step'.

To start click 'Next Step' below when you are ready to begin, this questionnaire will take around 15 minutes to complete.

Introduction
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Enter your name

Please enter your name, this information is essential for verifying your identity and maintaining accurate medical records.

*Title:
*Full name:
Personal Information
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Enter your date of birth

Please enter your date of birth this information is essential for verifying your identity and maintaining accurate medical records.

*Date of birth
Personal Information
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Please enter your address & postcode

Please ensure that you accurately fill out your address details. This information is crucial for our records and enables us to provide you with the best possible care and service.

*Address:
*Postcode:
Personal Information
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Please enter your phone number & email

Please enter your phone number and email address. This information is important for us to contact you promptly and send any necessary updates or communications regarding your care.

*Phone number:
*Email address:
Personal Information
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What is your marital status?

Please confirm your current marital status below.

*Marital status:
Personal Information
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What are your religious beliefs?

Please enter your religious belief below if you have one.

*Religious beliefs:
Personal Information
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What is your first language?

This information helps us understand your communication preferences and ensures we can provide you with the best possible care and support.

*First language:
Personal Information
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What is your ethnic status?

We ask for your ethnic status to provide personalised care and identify any specific health risks. Your information helps us serve you better.

*Ethnic status:
Personal Information
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What is your employment status?

We ask for your employment status to better understand your needs and tailor our services accordingly. This helps us provide you with the most relevant healthcare support.

*Employment Status:
Personal Information
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Have you had any operations?

We ask about any past operations to ensure we have a complete understanding of your medical history.

If yes, please list operations and dates, if known:
Medical History
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Have you received a blood transfusion before 1996?

We ask this to assess any potential health risks related to blood transfusions before 1996

If Yes, please list the date when:
Medical History
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Are there any investigations/referrals outstanding from your previous GP?

We ask this to ensure continuity of care, follow up on ongoing issues, and prevent treatment delays.

If Yes, please arrange to see the doctor when convenient.
Medical History
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Have you suffered from any of the following?

We ask this to identify any existing or past health conditions that may impact your care.

If No, please click next step.
Medical History
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Any other major illnesses?

Please let us know of any other major illnesses not listed to ensure we understand your health fully and provide the best care.

If Yes, please list:
Medical History
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Are you allergic to any drugs?

We ask this to ensure your safety and avoid prescribing any medications that may cause an allergic reaction.

If Yes, please list:
Medical History
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Are you on regular medication?

We ask this to ensure safe and effective treatment, avoiding interactions with any prescribed medications.

If Yes, please list:
Medical History
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Do you have a flu vaccination annually?

We ask this to ensure you’re up to date with flu protection and can offer advice if needed.

Immunisations
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Have you had a pneumococcal vaccination?

We ask this to ensure you’re up to date with pneumococcal protection and can offer advice if needed.

Immunisations
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Have your parents, brothers or sisters suffered with any of the following:

We ask this to identify any family history of medical conditions, helping us assess potential health risks and provide appropriate care.

If No, please click next step.
Family History
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Any other family illnesses?

If any close family members have had illnesses not listed on the previous page, please let us know. This helps us fully understand your health and provide the best care.

If Yes, please list:
Family History
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Have you ever been a smoker?

We ask this to assess any potential health risks and provide appropriate support if needed.

If Yes, please input how many cigarettes you would smoke a day on average:
Lifestyle
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If an ex-smoker enter the date stopped

We ask this to assess any potential health risks and provide appropriate support if needed.

If you have given up smoking, enter the date you stopped, please skip if this is not relevant to you:
If you smoke and would like to quit, our Practice Nurse is here to support and guide you.
Lifestyle
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Do you exercise?

We ask this to understand your activity levels and offer guidance on maintaining a healthy lifestyle.

If Yes, enter the number of times per week & type:
Lifestyle
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Do you drink alcohol?

We ask this to assess your alcohol intake and provide any necessary health advice or support.

If Yes, how much alcohol do you drink in a week (in units):
(a unit = 1 small glass of wine, a single measure of spirits, or ½ pt beer)
Lifestyle
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How often do you consume alcohol?

We ask this to understand your drinking habits and offer any necessary health advice or support.

*How often do you consume six or more drinks on one occasion (eight or more for men)?
Lifestyle
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In the past year, how often have you forgotten events due to drinking?

We ask this to understand your drinking habits and offer any necessary health advice or support.

Lifestyle
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In the past year, how often has drinking prevented you from fulfilling your responsibilities?

We ask this to understand your drinking habits and offer any necessary health advice or support.

Lifestyle
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In the past year, has anyone expressed concern about your drinking or suggested you cut down?

We ask this to understand your drinking habits and offer any necessary health advice or support.

Lifestyle
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Are you a Military Veteran?

We ask this to recognise your service and ensure you receive any relevant support or healthcare benefits available to veterans.

Military Veteran
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Are you a carer?

If you are a carer please complete the details of the person you care for.

Name:
Address:
Phone number:
Carer Information
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Do you have a carer?

If you have a carer please complete the details of the person who cares for you.

Name:
Address:
Phone number:
Carer Information
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Do you wish to disclose information about your health to your carer?

Please tick the box below to consent to sharing your health information with your carer.

Carer Information
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(Women) Do you use contraception?

We ask this to provide appropriate healthcare advice and support for your reproductive health.

If Yes, please list:
Womens Health
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Have you ever had a cervical smear?

We ask this to ensure you are up to date with cervical screening and can offer any necessary advice or support.

If Yes, state date of test (if known):
Test result (if known):
Womens Health
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Have you ever been for breast screening?

We ask this to ensure you are up to date with breast screening and can provide any necessary support or advice.

If Yes, state date of test (if known):
Womens Health
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Confirm Submission

Please click 'complete submission' below!

After reviewing the questionnaire you submitted, we may invite you to book an appointment with us if you have a long-term condition that requires close and careful management.

Confirmation
Complete
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