NEW PATIENT QUESTIONNAIRE
In an endeavour to gain as much medical information about you before receiving your notes from your previous
doctor, please complete this form and hand to Reception together with your Registration Form. Thank you.
Personal Details
Surname………………………………..
Previous Surname……………….
First Name……………………………..
Date of Birth…………………….
Address………………………………………………………………………………….
Postcode………………………………..
Telephone No…………………...
Email……………………………………
Mobile No………………………
Consent to SMS messages Yes/No
Occupation……………………………..
Are you Ex Military? Yes / No
Are you a carer?
Yes / No
Definition of a carer
Do you provide unpaid support to a relative, partner, or friend who is ill, frail, disabled or has mental health or substance
misuse problems?
Relationship of person you are caring for ……………………….. Name of registered at this surgery……………………….
Do you have a carer?
Name of Carer ……………..……………………… Telephone number of Carer………………………………
Ethnic Group, Choose one section from A-E and tick the appropriate box
A White
B Mixed
C Asian/Asian British
British 
White/Black Caribbean 
Indian 
Irish 
White/Black African 
Pakistani 
Any other White 
Background, please write
in………………………..
White/Asian 
Bangladeshi 
Any other mixed 
please write
in …………………….
Any other Asian 
background please write
in……………………
D Black/Black British
E Other Ethnic Group
Caribbean 
Chinese 
African 
Any other Ethnic Group 
please write in
…………………………….
Any other Black
background please write in
……………………….
English spoken
Yes 
No 
First Language ………………………
Male 
Gender:
Status:
Single 
Separated

Female 
Married

Divorced

Widowed

Past Medical/Surgical History including dates
...................................................................................................................................................................................
...................................................................................................................................................................................
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Illnesses
Stroke 
Diabetes 
Cancer 
TB 
Asthma 
High B/P 
Glaucoma 
Epilepsy 
Heart Problems 
Any other long term or serious
illnesses………………………………………………....................................................
Mental Health
Stress/Anxiety 
Have you or are you suffering with
Depression 
Other 
History of Overdose/Self Harm
Yes 
No 
If yes give details ……………………………………………………………………….
Allergies
None 
Drugs 
Other 
Please specify…………………………………………………………………………...
Current Medication & Dosage (Inc contraceptive pill)
Please provide evidence of medication prescribed, this can be obtained from your previous surgery
Immunisations
Please provide evidence of immunisations you have received, giving dates (Important for students and
children). This can be obtained from your previous surgery.
FEMALE PATIENTS ONLY
Date of last cervical smear………………Any abnormal smears? Yes  No 
Type of contraception if used …………………………..…..
Are you currently pregnant? Yes  No 
Number of pregnancies…………
(Please include miscarriages/terminations)
Family History
Please advise if any parent, grandparent, sister, brother have suffered or died from any of the following
conditions:
Heart disease (hypertension, angina, heart attack)
Stroke
Diabetes (Type 1 or 2)
Asthma




Relationship
……………………. (e.g mother)
……..………………
……………………..
……………………..
Alcohol intake
Intake of units in a normal week?
1 unit = 1 small glass wine, single measure of spirit, 1/2 pint of beer
Beer/cider/lager………………..
Wine……………………
Single measures of spirit…………………….
Teetotal 
Smoking
Never smoked 
Cigarettes 
Ex smoker 
Cigars 
Smoker 
Roll-ups 
Pipe 
How many/oz per day?.....................................
Exercise and Activity
None 
Light 
Moderate 
Daily 
Weekly 
Occasionally 
Heavy 
Date of completing questionnaire ……………………….
Summary Care Record - Your medication, allergies and sensitivities are shared with other NHS organisations
i.e. hospitals, paramedics.
NHS Care data - Confidential information from your medical records can be used by the NHS to improve the
services offered so we can provide the best possible care for everyone. This information along with your
postcode and NHS number but not your name, are sent to a secure system where it can be linked with other
health information. This allows those planning NHS services or carrying out medical research to use
information from different parts of the NHS in a way which does not identify you.
If you wish to opt out of either of the above please ask reception for the relevant opt out form
PATIENT PARTICIPATION GROUP
We would like to know how we can improve our service to you and how you perceive our surgery and staff.
To help us with this, we have set up a virtual patient representation group so that you can have your say. We
will ask the members of this representative group some questions from time to time, such as what you think
about our opening times or the quality of the care or service you receive. We will contact you via email and
keep our surveys succinct so it shouldn’t take too much of your time.
We aim to gather around a hundred patients from as broad a spectrum as possible to get a truly representative
sample. We need young people, workers, retirees, people with long term conditions and people from non-British
ethnic groups.
If you are interested in joining the patient group please ask reception for a form or alternatively you can log in
to our website www.dickensplacesurgery.co.uk
……………………………………………………………………………………………………………………...
ADMINISTRATION ONLY TO COMPLETE:
ID Seen:
Passport

Driving Licence

Home Office Letter

Utility Bill

Bank Statement

Other (Please state)
Date/Time of New Patient Medical:
…………………