In an emergency call 999. Out-of-hours call 111. Denaby Medical Practice: 01709 514443

Denaby Medical Practice

New patient health questionnaire (adults)

Complete this form and our team will process your request. We aim to respond within 2 working days.

This form is not for urgent problems. If you need help today, phone the practice on 01709 514443. In an emergency call 999.

NHS Number (optional)

First Names

Surname

Previous Surname (optional)

Date of Birth

Gender

Female

Male

Ethnicity

First Spoken Language

Town and Country of Birth

AddressStreet address

Town or city

Postcode

Main Contact Number

Home Contact Number (optional)

Email (optional)

Your previous address in the UK (optional)Street address

Town or city

Postcode

Name of doctor while at that address (optional)

Address of previous doctor (optional)Street address

Town or city

Postcode

Your first UK address where registered with a GP (optional)Street address

Town or city

Postcode

If previously resident in UK, date of leaving (optional)

Date you first came to live in the UK (optional)

Are you ordinarily a resident in the UK?

Yes

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? (optional)

Yes

Sex and gender identity – Which one of the following best describes how you think of yourself?

Male (including trans men)

Female (including trans women)

Non-binary

Prefer not to say

In another way

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

Yes

Prefer not to say

Do you speak English?

Yes

Do you read English?

Yes

Are you a British Sign Language user?

Yes

What is your main spoken language?

Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) (optional)

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?

Yes

Do you have access to secure housing?

Yes

What is your current immigration status? (optional)

Asylum Seeker

Failed Asylum Seeker

Do you have caring responsibilities?

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Do you have a carer?

Yes

Full Name

Relationship to you

Contact Number

Are they your next of kin?

Yes

Do you give us permission to discuss your medical records with them?

Yes

Height

Weight

Smoking Status

Current Smoker

Ex Smoker

Never Smoked

What do you smoke?e.g. Cigarettes, Vape, Cigars

How many do you smoke per day?

Are you interested in advice on how to quit?

Yes

Please state how much exercise and what type of exercise you do per week (optional)

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?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Do you have any significant family history we should be aware of? (optional)

Major Illnesses (optional)Please include dates

Past Operations (optional)Please include dates

Family History Illnesses (optional)Please include dates

Current Medication (optional)

We routinely offer HIV screening would you be interested in being screened?

Yes

Sight

Good

Poor

Registered Blind

Hearing

Good

Poor

Partially Deaf

Deaf

Do you have any allergies?

Yes

Please specify what you are allergic to, what happens and when you had your first reaction

Please list any immunisations/vaccinations you have had (optional)Please include dates

Do you consent to having a Summary Care Record?

Yes

Declaration (optional)

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

SignatureYour Full Name

Date