D DOCTORS KIRBY, PAGE, McMILLEN, TOMKINSON & WALL

NEW PATIENT REGISTRATION QUESTIONNAIRE

Name: Date of Birth
Do you have any medication on repeat prescription? Yes / No
Do you have a preferred GP in the practice? If so, please specify
None Dr. Kirby Dr. Page Dr. Tomkinson Dr Wall Dr McMillen
Are you a carer? Yes / No

Schoolchildren only –

Please specify school / Is your child up to date with immunisations?
Yes / No
Please circle religion / Church of England / Roman Catholic / Non-conformist / Methodist
Jehovah’s witness / Jewish / Pentecostal / Hindu
Christian / Buddhist / Sikh / Atheist

Other – please specify

Please circle ethnicity / White / Black Caribbean / Black African / Black other
Indian / Pakistani / Bangladeshi

Other – please specify

Please state sexual orientation (not compulsory) / Heterosexual Homosexual Bisexual Gay Lesbian
Please indicate main spoken language / Please specify your place of Birth
Smoking / Have you ever smoked? Yes / No / Never
Do you currently smoke? Yes / No / If yes how many per day?
Are you an ex-smoker? Yes / No /
If yes, how many per day?
Alcohol (AUDIT-C) / How often do you have a drink containing alcohol?
Never / Monthly or less / 2-4 times a month / 2-3 times a week / 4 or more times a week
How many standard drinks containing alcohol do you have on a typical day - when you are drinking?
1 or 2 / 3 or 4 / 5 or 6 / 7 or 8 / 10 or more
How often do you have 6 or more drinks on one occasion?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Are you allergic to any medication?
Do you have an e-mail address or mobile number ?
Would you like to receive an SMS message for your appointments or your test results PLEASE ENSURE WE HAVE YOUR MOBILE NUMBER
Have you ever been a member of the armed forces ? / YES / NO
Do you require information in a specific format, ie large print, sign language ?

You can register for online access to book / cancel appointments,order repeat prescriptions or view your medical record at https://www.emisaccess.co.uk. Please ask at reception for a information.