REGISTRATION QUESTIONNAIRE

Welcome to Whitchurch Health Centre.

When you are registered with us your old medical records from your previous doctor will automatically be sent to us. We would be very grateful if you could fill in the following questionnaire as completely as possible, and give it back to the receptionist. Thank you.

Name / Date of Birth
Home Telephone / Occupation
Mobile Phone / Email

1. How would you like to receive correspondence from us: E-mail/Phone/Letter /Text

2. Are you a CARERYES/NOWho do you care for ……………………………………………

Do YOU have a carerYES/No Who cares for you.………………………………………….

3. Please notify us at the time of registration if you have any sight and/or hearing impairments and need information in a different format.

4. Please state which ethnicity you are, this is very important for us to record

…………………………………………………………………………………………………………………………….

5. Lifestyle Data – Please circle your answers

Have you ever smoked? / Yes / No
If you answered Yes and you still smoke, please indicate how many of what per day
If you smoke Roll ups how many oz’s per week
Are you a user of an electronic cigarette? / Yes or No
If an ex-smoker, please give the same details and the date you stopped smoking

6. Please answer the following questions using the Alcohol Intake key to help

Alcohol Intakekey – A Standard drink = 1 Unit (1pt = 2 units, 1 small wine = 1 unit, 1 single measure = 1 unit)

How many alcohol drinks do you
drink in a typical week. / Pints / Spirits (single measure) / Wine (small glass)

7. Exercise: How much exercise do you take in a week? …………………………………

8. Please list any current medical problems

9. Past Medical History

Please give details of any serious illnesses, operations or admissions to hospital. Please include any important medical condition for which you have received treatment

10. Electronic Prescription Service

If you wish your prescription request to be processed through the EPS system please inform us of your Nominated Pharmacy. For more information on this service please pick up a leaflet at reception.

11. Allergies or severe side effects with Drugs and Tablets

Please tick A, B or C below depending on whether you are allergic to or develop reactions to drugs or tablets and if so which drugs.

A I am not allergic to any drugs [ ]

B I am allergic to the following drugs [ ]

Drug or tablet / Description of side effects / Date noticed

C. I am allergic to some tablets but I cannot remember their name [ ]

12. Personal Dataheight……………weight………………..

13. Female patients only

Are you currently pregnant, if yes please tell us your estimated date of delivery?

......

14. Family history

Please list any serious illnesses that have occurred in your immediate family

(i.e. Father/Mother/Brother/Sister), such as heart disease, stroke, high blood pressure, diabetes, asthma, cancer, Maternal hip fractures.

NOTE: THIS ONLY APPLIES TO RELATIVES WHO WERE UNDER 70 YEARS OF AGE WHEN THE DISEASE STARTED.

Relation / Disease /

Approximate age at onset

15. Please tick this box if you would like us to invite you in for a new patient health check?

Thank you for taking the time to complete this questionnaire. Please pass it to a Receptionist for processing.