Please indicate which practice
you would like to be registered with.
ARMADA
THE GREEN
PHOTO VERIFIED
ADDRESS VERIFIED
CHECKED BY
REGISTRATION QUESTIONNAIRE
Welcome to Whitchurch Health Centre.
When you are registered with us your old medical records from your previous doctor will
automatically be sent to us. We would be very grateful if you could fill in the following
questionnaire as completely as possible, and give it back to the receptionist. Thank you.
Name
Home Telephone
Mobile Phone
Email
Date of Birth
Occupation
Marital Status
1. How would you like to receive correspondence from us: E-mail/Phone/Letter /Text
2. Are you a CARER
YES/NO
Do YOU have a carer
Who do you care for ……………………………………………
YES/No Who cares for you.………………………………………….
3. Please state which ethnicity you are, this is very important for us to record
…………………………………………………………………………………………………………………………….
4. Lifestyle Data – Please circle your answers
Have you ever smoked?
If you answered Yes and you still smoke,
please indicate how many of what per day
If you smoke Roll ups how many ozs per
week
If an ex-smoker, please give the same details
and the date you stopped smoking
Yes
No
5. Please answer the following questions using the Alcohol Intake key to help
Alcohol Intake key – A Standard drink = 1 Unit (1pt = 2 units, 1 small wine = 1 unit, 1 single measure = 1
unit)
How often do you have a
drink that contains
alcohol?
How many standard
alcohol drinks do you have
on a typical day when you
are drinking
How often do you have 6
or more standard drinks
on one occasion
Never
Monthly or
less
2 – 4 times
per month
2 – 3 times
per week
4+ times per
week
10+
Never
How many alcohol drinks do you
drink in a typical week.
Less than
monthly
Pints
Monthly
Spirits (single
measure)
P.T.O
Weekly
Daily or
almost daily
Wine (small
glass)
6. Exercise: How much exercise do you take in a week? …………………………………
7. Please list any current medical problems
8. Past Medical History
Please give details of any serious illnesses, operations or admissions to hospital. Please include any
important medical condition for which you have received treatment
9. Allergies or severe side effects with Drugs and Tablets
Please tick A, B or C below depending on whether you are allergic to or develop reactions to drugs or
tablets and if so which drugs.
A I am not allergic to any drugs [
]
B I am allergic to the following drugs [
Drug or tablet
]
Description of side effects
Date
noticed
C. I am allergic to some tablets but I cannot remember their name [
10. Personal Data
height……………
]
weight………………..
11. Female patients only
Are you currently pregnant, if yes please tell us your estimated date of delivery?
.....................................................................................................................
12. Family history
Please list any serious illnesses that have occurred in your immediate family
(i.e. Father/Mother/Brother/Sister), such as heart disease, stroke, high blood pressure, diabetes,
asthma, cancer, Maternal hip fractures.
NOTE: THIS ONLY APPLIES TO RELATIVES WHO WERE UNDER 70 YEARS OF AGE WHEN THE
DISEASE STARTED.
Relation
Disease
Approximate age at onset
13. Please tick this box if you would like us to invite you in for a new patient health check?
Thank you for taking the time to complete this questionnaire. Please pass it to a Receptionist
for processing.