New Patient

Registration Form

PLEASE COMPLETE ALL SECTIONS AND SIGN (*Mandatory Fields)

PERSONAL DETAILS
FIRST NAME: / * / TITLE
MIDDLE NAME: / DOB: / *
SURNAME: / * / NATIONALITY:
ADDRESS:
POST CODE: / *
MARITAL STATUS: / MALE / FEMALE *
HOME NO: / MOBILE NO: / *
WORK NO: / EMAIL: / CONSENT
YES/NO
NEXT OF KIN / * / RELATIONSHIP:
ADDRESS:
POST CODE:
PHONE NO: / MOBILE NO:

OFFICE USE ONLY

Nurse Appointment Booked / Date of Appointment / Attended Appointment / Signature
Pharmacist Reviewed Medication / Date Reviewed / Script Generated / Signature
Medication Repeats added by GP / Date of Appointment / Attended Appointment / Signature
PAST MEDICAL HISTORY (Please list any operations, investigations or serious illness)
Date / Details
CURRENT MEDICATION: ITEMISE ALL MEDICATION OR ATTACH PREVIOUS GP’S REORDER FORM
Name of Medication / Form (Capsule/Tablet) / Frequency / Strength
CURRENT OVER THE COUNTER MEDICATION:
Name of Medication / Form (Capsule/Tablet) / Frequency / Strength
DO YOU HAVE ANY ALLERGIES? / YES/NO
Please list:
FEMALES
When was your last cervical smear taken?
What was the result of your last smear?
How many pregnancies have you had?
Are you using contraception at present?
Contraception Used – Please circle
Oral Contraception PiIl / Coil / Implant in Arm / Condoms / Injection
LIFESTYLE
OCCUPATION:
HEIGHT: / WEIGHT:
SMOKE: / YES/NO / EX SMOKER: / YES/NO
Would you like help to stop? YES/NO How many per day?
ALCOHOL CONSUMPTION: / YES/NO
How much do you drink per week?
EXERCISE:
Do you exercise on a regular basis? / YES/NO
Please list exercise
DIET:
eKIS Consent (Electronic Knowledge Information Sharing)
Are you happy for your medical summary to be accessed by NHS24, hospital doctors and ambulance staff? YES/NO
CARER
Are you a carer? / YES/NO
If Yes, who do you care for?
Are you cared for? / YES/NO
If Yes, who do you care for?
Any other information you think we should know?
FAMILY HISTORY
Is there any family history of diabetes / YES/NO
If YES, please provide details and age of onset
Is there any family history of heart problems? / YES/NO
If YES, please provide details and age of onset
Is there any family history of stroke? / YES/NO
If YES, please provide details and age of onset
Please provide the following information:
Relative / Date of Birth / Any Serious Illness / Cause of death, age person died if applicable
Father
Mother
Brother(s)
Sister(s)
Husband
Wife
Children
PREVIOUS ADDRESS:
Signature: / *
Date: