New Patient Questionnaire - Adult & Under 14s

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All fields are mandatory

All questions marked with a * are mandatory

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Introduction

Please try and complete this questionnaire in full to give your new doctor any important information about your health. All information will be kept strictly confidential.

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Personal Details

Housing & Employment

Are you having problems with your housing?:

Employment status - are you:

Do you have difficulty making ends meet at the end of the month?:

Do you have a disability, impairment or sensory loss?:

Are you lonely:

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Medical History

Have you ever had any of the following?: *

Do you find it hard to understand information given to you about your health, or treatments you may be receiving? :

Family History

Has anyone in your immediate family had any of the following?: *

What is your weight

What is your height

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New Patient Check: HIV and TB Screening

All new patients will require a new patient health check with a member of our nursing team.

We encourage HIV screening for all new patients; this can now be done as an instant finger-prick test.

All patients will be offered an HIV test at the new patient check, please indicate if you are happy to be screened? : *

Have you moved to the UK in the last 5 years? : *

Recent immigrants from certain countries are also eligible for TB screening – ask at your New Patient Check.

For Women and other people with a cervix

Have you ever had an abnormal smear :

Were you treated in the colposcopy clinic? :

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Questionnaire - Adult & Under 14s

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