New Patient Assessment Form - Ferry Road Health Centre
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2NEW PATIENT ASSESSMENT FORM
Dear Patient – We kindly ask that you fill out this New Patient Questionnaire. Please be aware that the
questions below may indicate that you need an appointment with a Nurse or Doctor. Please complete all
sections. Thank you.
Name
DOB
Postcode
Sex
Male
Email
Telephone
If mobile, I consent to text reminders and
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I consent to email contact from the surgery
messages from the surgery
Ethnic Group
First Language
(e.g. British/mixed British, Indian or British Indian, Pakistani or
British Pakistani, Irish, White or Black African)
Do you have a Long-term condition? Please tick if yes.
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Heart
Diabetes
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High Blood Pressure
Respiratory / lung condition
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Epilepsy
Cancer
Medicines
Do you take any regular medication?
YES / NO
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If you live in Rye which chemist would you like to use
Boots
Day Lewis
If you live outside of Rye we will dispense your medication
Allergies
Do you have any allergies or reactions that you are aware of? YES / NO
Please provide details – including what it is and what happens…………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
Any hospital admissions within the last 6 months? YES / NO
If yes, what for ? …………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………
Smoking status –Please tick the appropriate box.
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□ Current Smoker - Age Started ______ per a day_____
Never smoked
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Ex-Smoker (date: ___/___/_____)
If you are a current smoker, would you like to stop smoking? YES / NO
Family History
Do you have any significant family history in your mother/ father or siblings? YES / NO Further
Details: ………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………
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