Chapel Lane, Wickham Market, Woodbridge, IP13 0SB and

Rendlesham Surgery, 6 Acer Road, Rendlesham, IP12 2GA

Contact Details

HEALTH QUESTIONNAIRE

Health questionnaire for Newly Registered Patients

Personal Details

Marital Status: Title: Full Name: Previous Surname (if applicable): Date of Birth: Age: Gender: Place of Birth: Current Address: Previous Address: NHS Number (if known): Email Address: Daytime Telephone Number: Mobile Telephone Number:

Which ethnic group do you belong to:

British / Mixed British

Irish

Other White Background

White / Black Caribbean

White / Black African

Other Mixed Background

Indian / British Indian

Pakistani / British Pakistani

Bangladeshi / British Bangladeshi

Other Asian Background

Caribbean

Chinese

Other Black Background

Other Ethnic Group

First Language: Next of Kin (name, relationship and telephone number): Previous GP in United Kingdom (GPs name and surgery name, postcode):

Are you from abroad?

Yes

Date you first came to live in the UK?

Are you returning from the army?

Yes

Have you been a patient at the Surgery before?

Health Questionnaire

Have you been a patient at the Surgery before?

Yes

If so what year?

Do you have any special communication needs?

Smoking habits?

Smoker

Never Smoked

Ex-Smoker

Would you like support to quit smoking?

Yes

Date ceased (if an ex-smoker)

What is your current height?

What is your current weight?

Do you have any of the following diseases?

Asthma

Cancer

Diabetes

Chronic Heart Disease

Chronic Kidney Disease

Chronic Lung Disease

Epilepsy

Stroke / TIA

Hypertension (high blood pressure)

Hypothyroidism (underactive thyroid)

Mental Health (give details below)

Previous Operations (give details below)

Please give details of any Mental Health, Previous Operations or any other significant medical history: Please give details of any Allergies:

Are you on current medication (repeat)?

Yes

You need to book in for a medication review with your registered GP before we can reissue.

Please give details of family (parents, siblings, grandparents) medical history, any major operations or whether they have any of the following conditions: Asthma, Cancer, Diabetes, Chronic Heart Disease, Chronic Kidney Disease, Chronic Lung Disease, Epilepsy, Stroke / TIA, Hypertension (high blood pressure), Hypothyroidism (under-active thyroid), Mental Health or Previous Operations:

Are you a full time carer for a dependant person?

Yes

If yes, please give name, address and telephone number:

Do you have a carer?

Yes

If yes, please give name, address and telephone number:

How did you hear about us?

NHS Choices

Surgery Website

Recommendation from a friend

Other

If 'Other' please give details

Are you aware of what a Summary Care Record is and that you will be automatically enrolled unless you opt out?

Yes

Would you like PatientAccess to enable you to book appointments, order prescriptions and view your medication and allergies history online? If yes please register via our home page link.

Yes

Send Your Request

By clicking the Submit button below I confirm that I am an ordinary resident at an address within the practice area and that I am legally entitled to register with an NHS GP.

Thank you for registering with us online. Your form will be actioned with 48 hours. Before you are able to use our services we must see you in person with id that includes your current address on it. For example photo driving licence or passport accompanied with a utility bill.

Thank you! Your submission has been received!

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HEALTH QUESTIONNAIRE

Personal Details

Send Your Request

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