New Patient Registration Form Adult Step 1 of 2 50% File OptionalMax. file size: 1 GB.NHS Number OptionalTitlePlease SelectMrMrsMissMsDrOtherFirst NamesSurnameDo you have a previous surname? Yes No Previous SurnameDate of Birth Day Month Year Gender Male Female Ethnic Origin White – British White – Irish Other White Mixed – White and black Caribbean Mixed – White and black African Mixed – White and Asian Other mixed Asian/British Asian – Indian Asian/British Asian – Pakistani Asian/British Asian – Bangladeshi Other Asian Black British – Caribbean Black British – African Other black Chinese Any other Not Stated Please SpecifiyTown and Country of BirthAddress Street Address Address Line 2 City Postcode Main Contact NumberEmail Enter Email Confirm Email Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Optional Address Line 2 Optional City Optional County Optional Postcode Optional Name of previous GP SurgeryAddress of previous GP Surgery Street Address Address Line 2 City County Postcode If you are from abroad:Your first address where registered with a GP Street Address Optional Address Line 2 Optional City Optional County Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional Armed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes No New Patient Health QuestionnaireFull NameMobile NumberHome OptionalWork OptionalEmail Enter Email Confirm Email Gender Male Female Date of Birth Day Month Year Relationship StatusPlease SelectMarriedSingleDivorcedWidowedCohabitingPrefer not to sayOccupationPlace of BirthDo you need an interpreter? Yes No Which Language?Are you a CARER or is someone a carer for you?Please SelectI am a carerI have a carerNeitherEthnic Origin White – British White – Irish Other White Mixed – White and black Caribbean Mixed – White and black African Mixed – White and Asian Other mixed Asian/British Asian – Indian Asian/British Asian – Pakistani Asian/British Asian – Bangladeshi Other Asian Black British – Caribbean Black British – African Other black Chinese Any other Not Stated OtherNEXT OF KIN (someone we can contact in an emergency)Next of Kin Contact NumberNext of Kin Email Optional Relationship to you (for example: Mother, Father)Illnesses, Accidents & OperationsMedicationsAre you Allergic to anything?Do you have a Disability? Yes No Please give detailsHEIGHT AND WEIGHTHeight – Unit of Measurement Imperial Metric HeightHeightHeightWeight – Unit of Measurement Imperial Metric WeightWeightThis field is hidden when viewing the formHidden Field (Imperial height to centimeters) OptionalThis field is hidden when viewing the formHidden Field (Imperial weight to metric) OptionalBMIBMI OptionalBLOOD PRESSUREIf KnownHigher number (systolic) OptionalLower number (diastolic) OptionalFAMILY HISTORYDo you or anyone in your family have any of the following (Please give relationship of family member e.g.: Maternal or Paternal Grandmother: / Grandfather You DIABETES HIGH BLOOD PRESSURE HEART ATTACK STROKE ASTHMA EPILEPSY OR FITS SKIN DISEASE NERVOUS DISORDERS CANCER KIDNEY DISEASE DEPRESSION ANY OTHER Family Member DIABETES HIGH BLOOD PRESSURE HEART ATTACK STROKE ASTHMA EPILEPSY OR FITS SKIN DISEASE NERVOUS DISORDERS CANCER KIDNEY DISEASE DEPRESSION ANY OTHER Family member with Diabetes:Family member with High Blood Pressure:Family member with Heart Attack:Family member with Stroke:Family member with Asthma:Family member with Epilepsy or Fits:Family member with Skin Disease:Family member with Nervous Disorders:Family member with Cancer:Family member with Kidney Disease:Family member with Depression:Please state which other and which family member:Do you smoke? Yes No Ex Smoker Do you use electronic cigarettes? Yes No How many cigarettes etc. do or did you smoke a day?How long have you been smoking (years)?When did you stop smoking?DO YOU WANT HELP TO GIVE UP SMOKING? Yes No Please ask about the STOP SMOKING CLINICHow often do you have a drink containing alcohol? Never Monthly or less Two to four times a month Two to three times a week Four or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 or 9 10 or more How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Do you use contraceptives? E.g. the pill, condoms etc. Yes No Please give details..Have you ever had a Cervical Smear test? Yes No Date of last smear test Day Month Year Place where you had your smear testResult of testHave you had a Mammogram? Yes No Date of Mammogram Day Month Year Have you had a Hysterectomy? Yes No Date of Hysterectomy Day Month Year Please give dates/details of any live births or terminations OptionalUpload Proof of ID Drop files here or Select files Max. file size: 1 GB. Upload proof of address Drop files here or Select files Max. file size: 1 GB.
