New Patient Questionnaire V4

Last Updated: 13/11/2023

Your Contact Details

Title

First Name(s) *

Surname / Family Name *

Previous Surname

Date of Birth *

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Is your gender identity the same as the gender you were given at birth? *

Yes No

What is your gender? *

Female (including Trans Women)

Male (Including Trans Men)

Non-Binary

What is your sexual orientation? *

We currently use a text messaging service to remind patients of appointments, health campaigns etc, Do you give consent for us to contact you this way? *

Yes No

Would you like to register for Online Services where you can order repeat medication, book appointments online and view your medical record? *

Yes No

Communication Needs & Language / Ethnicity

Do you have any specific communication needs? *

Yes No

How can we support you with your communication needs? e.g. large font, yellow paper, loop system

What is your first language? *

Do you need an interpreter? *

Yes No

Ethnic Group *

If Under 18 Years of Age

If under 5 years of age, new registration information will be shared with the local health visiting team

Any previous Surnames?

Name of Nursery / School / College (or if not applicable please type N/A) *

Has there been any Child Protection issues previously (required by health authorities for all new registrations or if not applicable please type N/A) *

Are both parents registered at the surgery?

Yes No

If no - are you happy to share the details (name) of the other parent and GP practice? (please write in text box) *

About You

Do you have a carer? *

Yes No

If you answered yes to having a carer - please provide your carers name, relationship to you and a telephone number

Are you a carer yourself? *

Yes No

Are you registered disabled? *

Yes No

If yes, please give details

Have you ever been in the Armed Forces? *

Yes No

Medical Information

Women

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Signature

Signature *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Peterloo Medical Centre website

New Patient Questionnaire V4

Further Information