New Patient Application Form

What is your height? *

What is your weight? *

What is your first language? *

Do you need an interpreter? *

Yes No

What is your Ethnic Group? (Information requested by Dept of Health) *

White British

White Irish

White Other

Black British

Asian British

Other

Proof of Identity and Address Provided

We require Photographic ID + utility bill with permanent address

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

Joining the Practice

If you are eligible to join, you will become a patient of the practice but not with a particular GP. You may express a preference to consult a particular GP but cannot be guaranteed due to demand

Medical Information

Please list any serious illnesses / operations *

Please list any medications you are taking *

Are you allergic to any medicines or anything else? *

Yes No

If so, which?

Repeat Prescription Protocol

Please nominate a Pharmacy of your choice. There will be no prescription collection from the practice unless the GP has issued an acute prescription or on the day special request. Please allow 48 hours for repeat prescriptions to be processed. Prescription orders can be made via telephone or online

Have you had a cervical smear?

Yes No

If 'yes', please state when and where

Have you had a mammogram?

Yes No

If 'yes', where did you have it done?

Do you smoke? *

Never smoked

Smoker

Ex-smoker

If 'Ex-Smoker', when did you quit?

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

Alcohol

Alcohol unit guide:

Pint of lager/stout = 2.5 units

Bottle of lager/alcopop = 1.5 units

NI pub measure of spirits/shot = 1.5 units

Bottle of spirits eg vodka, gin etc = 30 units

Glass of wine (187.5ml) = 2.25 units

Bottle of wine = 9 units

How often do you have a drink containing alcohol? *

How often during the last 6 months have you failed to do what was normally expected from you because of your drinking? *

Have you or somebody else been injured as a result of your drinking? *

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had six or more units if female, or eight or more units if female, on a single occasion in the last year? *

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

Please note

To minimise risk of tolerance and addiction, we do not prescribe benzodiazepines on a regular basis. On joining the practice, you may be required to commence a benzodiazepine reduction programme to come off this medication.

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New Patient Application Form

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