Woodstock Surgery
Park Lane
Woodstock
Oxfordshire
Telephone: 01993 811452
www.woodstocksurgery.co.uk
NEW PATIENTS
Welcome to Woodstock Surgery. Please complete the new patient registration
form and questionnaire as clearly and fully as possible. We will use this
information to help care for you until your notes arrive from your previous
practice.
We will require some identification and proof that you are resident within our
practice boundary.
If you are registering from overseas please be aware that you may not
automatically be entitled to secondary care under the NHS (for example
hospital care).
If you have repeat prescriptions please arrange for a new patient check with a
doctor.
Check list

Registration Form (GMS1
New patient questionnaire
Photographic proof of identification
Proof of residency within the practice Boundary
List of current medication
Appointment made with GP (if applicable)
Completion of Carers Form (if applicable)
Summary Care Information: I have received the
new patient letter, SCR leaflet, OCR leaflet and Opt
out form.
Please tick in the box below to show that you
have received the information
WOODSTOCK SURGERY
New Patient – Health Questionnaire
Personal Details
Title and Last Name:
Forenames:
Place of Birth:
Address:
Date of birth:
Occupation:
Work telephone number:
Mobile number:
Children (ages):
Marital Status:
Home phone number:
Contact in an emergency:
Are you a veteran?
Ethnicity
Country of Origin:
First Language:

White
White & Black Caribbean
White & Black African
White & Asian
Asian or Asian British, Indian
/Pakistani/Bangladeshi/other
Black/Black/British
Caribbean/African/other Black background
Other ethnic group
Carers
Do you have significant (unpaid) caring responsibility for someone? Yes 
If 'yes' please complete part 4 of this form.
No 
Clinical
Are you currently under any medical care of any sort?
Current medication giving details of name, strength and frequency:
Do you suffer from any allergies?
Past Clinical Conditions including hospital admissions and operations:
There is an automatic height and weight machine in the corridor which will provide
you with a paper slip – this can then be attached to this form – please put your name
on the slip
Height::
Are you a :
Weight::
Current
Smoker
How many do
you smoke a
day?
Do you drink alcohol?
YES/ NO
Do you take energetic exercise?
YES/ NO
Date of last Polio immunisation::
Never
Smoked
When did you
stop smoking?
ExSmoker
How many units of alcohol
do you drink a week?
How many times a week?
Date of last tetanus injection:
For female patients only:
Are you pregnant?
Details of past
pregnancies
Have you had a
cervical smear?
Have you had breast
screening?
Have you had a
hysterectomy?
Details of any
contraception being
used:
YES/ NO
Due delivery date:
YES/ NO
Date of last smear:
YES/ NO
Date of last screening:
YES/ NO
Date:
Name
D.O.B:
Family History
If any members of your family have suffered from any of these illnesses, please state
their relationship to you and whether they are on your mother or fathers side. Put
the age of onset if you know it.
Condition
Relationship to you
Age of onset if known
Heart Attack
Angina
High Blood Pressure
Stroke
High Cholesterol
Diabetes
Cancer (Type)
Thyroid disease
Osteoporosis
Senile Dementia
Glaucoma
Asthma
........................................................................................................................................
CARERS IDENTIFICATION
If you are a carer we would like to support you. Please complete this form and hand
it in to reception with your registration .
We can also refer you, with your permission, to have your needs assessed by Social
and Health Care. A carer's assessment is your legal right and there is no charge for
this service
YOUR DETAILS
Name
Date of Birth
Address
Postcode
Telephone
number(s)
Any relevant
information
DETAILS FOR THE PERSON YOU LOOK AFTER
Name
Date of Birth
Address
Postcode
Telephone
number(s)
Any relevant
information