New patient health questionnaire – Northwood and Alvechurch Medical Practice

Step 1 of 2

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Have you completed the registration form for this practice?(Required)

It is important that you have completed the registration form as that is the first step to registering with the practice. The health questionnaire below is the second step in this process. Please ensure you complete both forms.

Yes, I have completed the online patient registration form

No, I have not completed the online patient registration form

It is important that you have completed the registration form as that is the first step to registering with the practice. The following health questionnaire is the second step in this process. Please complete the registration form first and then this form.

Who is being registered?(Required)

Please choose the correct age band so we can show you the correct questions below.

Adult over 16 years

Child from 13 to 16 years

Child from 1 to 12 years

Newborn up to 1 year

Patient's details

Title(Required)

Mrs

Miss

Other

First names(Required)

Surname(Required)

Date of birth(Required)

Day

Month

Year

Previous surnames

Sex(Required)

Male

Female

NHS Number

Find your NHS number

Town and country of birth(Required)

Home address(Required)

Postcode(Required)

Home telephone(Required)

Enter NONE if you do not have one

Mobile number(Required)

Enter NONE if you do not have one

Email address(Required)

Enter Email Confirm Email

Please help us trace your previous medical records by providing the following information

Your previous address in UK(Required)

Please enter N/A if not applicable

Name of previous GP practice while at that address(Required)

Please enter N/A if not applicable

Address of previous GP practice while at that address(Required)

Please enter N/A if not applicable

Occupation/Job (current/past)(Required)

Please enter N/A if not applicable

Are you retired?(Required)

Yes

Are you homeless?(Required)

Yes

If you are homeless, may we use the address you registered with for confidential post?(Required)

Yes

Do you have a social worker?(Required)

Yes

If yes, please provide the name and contact details(Required)

Further information

Adult's mobile number(Required)

This is the Adult's mobile phone number. If the child is over 13 please provide the mobile number for the responsible adult here and the child's mobile in the box below (it is only visible if the correct age is selected above).

Child's mobile number(Required)

Adult email(Required)

This is the Adult's email address. If the child is over 13 please provide the email address for the responsible adult here and the child's email in the box below (it is only visible if the correct age is selected above).

Enter Email Confirm Email

Child's email(Required)

Enter Email Confirm Email

Next of Kin

Next of Kin full name(Required)

Relationship to you(Required)

Please enter N/A if not applicable

Next of Kin contact number(Required)

Do they have any formal power of attorney for medical care? (if so, please attach the certificates below)(Required)

Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent

Yes

More about a child or newborn

Name of person with parental responsibility(Required)

Relationship to you(Required)

Name of GP surgery at which they are registered(Required)

Their current home address(Required)

Name and address of school/nursery attended(Required)

School/nursery phone number(Required)

Communication needs

What is your first language?(Required)

Do you require an interpreter?

We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.

Yes

Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record.

Hearing aid

British Sign Language

Makaton Sign Language

Lip reading

Guide dog

Large print

Braille

Do you have a learning disability?(Required)

Yes

Please provide further information

Your lifestyle

What is your height?(Required)

What is your weight?(Required)

How often do you physically exercise?(Required)

Daily

Weekly

Occasional

Smoking

Are you a smoker?(Required)

If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.

Yes

Never smoked

Ex-Smoker

How many per day?(Required)

Please send me smoking cessation services information(Required)

Yes

When did you quit?(Required)

Do you use an e-cigarette?(Required)

Ex-user

Yes

Alcohol

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2 to 4 times / month

2 to 3 times / week

4+ times / week

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

None

1 - 2

3 - 4

5 - 6

7 - 9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption

Part Two Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking?

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Yes, but not in the last year

Yes, during the last year

Score - part 2

0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

Medical information

Do you currently have or had any of the following?(Required)

Diabetes

Alzheimers Disease or Dementia

Epilepsy

Asthma

COPD

High Blood Pressure (Hypertension)

Heart Disease

Heart Failure

Stroke or Transient Ischaemic attacks

Angina

Under active thyroid

Kidney Disease

Depression or mental health problems

Cancer

None of these

Any other conditions, operations or hospital admission details:

Please list any immunisations or vaccinations you have had

Do you have any allergies?(Required)

Includes food, drug and environmental allergies

Yes

Allergy details(Required)

Are you currently receiving care elsewhere?(Required)

Please let us know if you are currently under the care of a Hospital or Consultant outside our area.

Yes

Please provide further information(Required)

Please list below your current repeat medication(Required)

Please enter N/A if not taking any repeat medication

Pharmacy choice(Required)

We are a paper-free surgery, as such our prescriptions are all sent electronically to a pharmacy of your choice. Please let us know which pharmacy you would like prescriptions to be sent to (this can be changed at a future date).

Family history

Are you adopted?(Required)

Yes

Does anyone in your family have or previously had any of the following(Required)

Cancer

Alzheimers Disease or Dementia

Asthma

COPD

High Blood Pressure (Hypertension)

Epilepsy

Diabetes

Kidney Disease

Liver Disease

Stroke

Heart Disease

Depression

Thyroid

None of the above

Please give any details if you have ticked any of the above

Females only

Please let us know the date of your last cervical screening (smear) test

(if you are over 25 years old)

Day

Month

Year

Have you had any children?(Required)

Yes

Please give the dates of birth of your children(Required)

Have you had a hysterectomy?(Required)

Yes

Please give the type and date of the hysterectomy(Required)

Do you have a coil or implant?(Required)

Yes

Please give the date when fitted(Required)

Looked after child/Child in care

A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.

Are you a looked after child?(Required)

Yes

Who are you living with?(Required)

I am living with foster parents

I am living in a residential children's home

I am living in residential settings (e.g. school or secure unit)

If yes, please provide the name and contact details(Required)

Disability

You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.

Do you have a disability?(Required)

Yes

Do you need information communicated to you in a specific format?(Required)

Yes

Do you need support when attending the surgery?(Required)

Yes

If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)

Organ donation

In England it is considered that you agree to become an organ donor when you die if:

you are over 18;
you have not opted out;
you are not in an excluded group.

Find out more on www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

Patient Participation Group

Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.

Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings

Yes please

New borns and under 5 immunisations

For new-born babies and children aged under 5 years, we require an up-to-date immunisation history. If you do not have this information please tick here(Required)

I do not have this information

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination

Yes

Unsure

I am less than 25 years old and have had a Meningitis C Vaccination

Yes

Unsure

Surgery communication consent

Would you like to register for online services?(Required)

You can book/cancel appointments, order prescriptions and see your read coded record and results online

Yes

Do you consent to receiving SMS messages?(Required)

These will be text messages relating to your care e.g. appointment reminders and when we need you to contact the surgery?

Yes

Can we contact you by email?(Required)

Yes

Signature

You may be asked to sign this form when you visit the practice and provide ID and proof of address. If you were born outside of the UK, you may be required to bring your Passport and Visa with you.

Please enter your full name below(Required)

Today's date(Required)

Day

Month

Year

Not for urgent medical help(Required)

Yes, I understand this form is not for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

This field is for validation purposes and should be left unchanged.