New Patient Registration Form and Questionnaire - St Triduanas Medical Practice

Title

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth (dd/mm/yyyy) *

NHS number or CHI number if known

Sex

Male

Female

Address *

Postcode *

Telephone *

Please help us trace your previous medical records by providing the following

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces

New Patient Questionnaire - Personal Details

Medical Information

Illnesses, accidents or operations. Please list all serious illnesses, accidents or operations with dates

Have you received a blood transfusion before 1996 or had an organ transplant prior to 1992?

Are you allergic to any medicines? *

Yes No

If yes, please list which medications you are allergic to and the type of reaction:

Do you have a carer? *

Yes No

If yes, please give details of your carer including contact details:

Are you a carer for someone else? *

Yes No

If yes, please give details:

Living Will / Advance Directive

Other clinical details

Do you smoke? *

Yes No

If no, have you ever smoked?

Yes No

If yes, how many cigarettes, cigars, or ounces of tobacco do you smoke per week?

How many units of alcohol do you drink in a week? *

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 *

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders? *

Yes No

Date of Birth of patient (dd/mm/yyyy) *

Please state if you are the patient, or signing on behalf of the patient *

Signature of patient

Signature on behalf of patient

Signature *

Relationship to patient (if you are registering for someone else)

Date *

NHS Organ Donor Registration

You have a choice about organ or tissue donation after your death. To find out more about why it is important that you take the time to make your donation decision and record it, got to www.organdonationscotland.org

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

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New Patient Registration Form (GMS1)V3 and Questionnaire

Further Information

New Patient Registration Form (GMS1)V3 and Questionnaire

Further Information

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