New Patient Online 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.

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

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

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.

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.

Please confirm your current marital status below.

Please enter your religious belief below if you have one.

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

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

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.

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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