New Patient Registration Form Page 2

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Your Ethnic Origin:
British/ mixed British
Irish
White (Other)
(select one)
White & Black Caribbean
Chinese
Other Mixed
White & Asian
Background
Indian /
Other Asian
Pakistani/ British Pakistani
Bangladeshi / Brit Bangladeshi
Brit Indian
Background
Caribbean
Other Black
Other
Ethnic Category
Background
not stated
Smoking and Alcohol Consumption:
yes
No
Yes
No
Are you currently a smoker?
Have you ever been a smoker?
Please confirm that you have complete the
If so, how many cigarettes / cigars / tobacco
alcohol questionnaire attached (16 years
do you smoke in a week?
and over)
Please bring a list of medications when you make you first GP appointment
Please inform the doctor of any known allergies you have
MEDICATION
Please inform the doctor if you have trouble taking your medication
Feet / inches
cm
Stones / lbs
Or kg
HEALTH :Your
Your weight:
or
height
Diabetes
Heart Attack
Heart attack under age of 60
Bowel Cancer
FAMILY MEDICAL
HISTORY :Are there any
Breast Cancer
High Blood Pressure
Asthma
Stroke
serious diseases that
affect your Parents,
Brothers or Sisters
Thyroid Disorder
Any other important Family Illness?
(tick all that apply)
Specific Needs:
Please detail below any specific needs you have so the Practice can ensure they are identified and accommodated
by taking the appropriate action: DO YOU HAVE ANY OF THE FOLLOWING
Any Speech, Hearing or Sight
Impairment [including the need for
an
‘Assistance Dog’
Any Physical disabilities
Any requirements you have to be
able to access the Practice premises
Any Mental disabilities
Any Religious or Cultural needs:
Person Cared For Contact Details:
If you are a Carer, please state the
name / address / phone number of
the person you care for:
Carer Contact Details:
If you have a Carer, please state
their name / address / phone
number and sign here if you wish us
Signed:
Date:
to disclose information about your
health to your Carer.
Patient
Signature on
Signature:
behalf of Patient:
2
Doc. Ref –
Version –
Filename: Identify Patient Needs Protocol + New Patient Registration Policy & Form Page of 3

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