The Village Surgery

The Village Surgery

12 Elbow Lane, Formby

L37 4AW

Telephone: 01704 878661

Fax: 01704 832488

New Patient Questionnaire

Welcome to our Practice, and thank you for registering with us. It may take some weeks before your records reach us and by answering the following questions you will enable us to provide better medical care. We also require TWO forms of identification from the following list to verify the registration address and name (Family name):

* Bank card / credit card * National Insurance / NHS number card

* Recent Bank Statement / utility bill * Recent correspondence from a government body

* Birth Certificate * For patients from overseas – a passport or ID card

Surname / Forenames (underline name by which you are known)
Previous Names / Male/Female Title
Date of Birth / Place of Birth
Marital Status
NHS No. / Are you a Carer? YES/NO
Do you have a carer? YES/NO
Carers Name
Address (and Postcode)
Email Address
Are you happy to be contacted by email?
YES NO / Home Telephone
Mobile Telephone
Are you happy to receive text messages from us? YES NO
Name of Next of Kin & Telephone No. / Name and address of previous GP
Please indicate here if you have any special needs regarding how you would like us to contact you (e.g. deaf, partially sighted, blind)
What is your first spoken language?
Ethnic Origin
White
British / Mixed
White and Black Caribbean / Asian or Asian British / Black or Black
British / Other Ethnic Groups
Indian / Caribbean / Chinese
Irish / White and Black African / Pakistani / African / Other Ethnic group
Any Other white background / White and Asian / Bangladeshi / Any other black background
Any other mixed background / Any other Asian background
Do you know that you can book appointments and submit prescriptions online?
(Please ask at reception for your log in details 7 days after submitting your application form)
Please indicate if you have a history of any of the following:
High blood pressure YES/NO
Stroke YES/NO
Heart Attack YES/NO
Angina YES/NO
Diabetes YES/NO
Asthma YES/NO / COPD (emphysema) YES/NO
Epilepsy YES/NO
Any other significant illness or operations?
Date of last tetanus vaccination / Allergies
Height / Weight
Do you smoke? YES/NO
If yes
please indicate cigarettes/cigars/pipe
How many per day? / If no, did you ever smoke YES/NO
If yes, when did you stop?
WE RUN SMOKING ADVICE CLINICS HERE AT THE PRACTICE. If you would like help to stop smoking please ask at reception for further details.
Do you drink Alcohol? YES/NO
If yes how much per week
Do you require an appt to discuss this? Yes/No / Do you exercise? YES/NO
How many times a week?
Current Medication:

Women aged between 24 and 64 only

Have you ever had a cervical smear? YES/NO / Date of most recent smear

Any other comments or suggestions?

For Staff use only: Indicate which item has been seen: Name, Signature

Bank card / credit card / Name
National Insurance / NHS number card
Recent Bank statement / utility bill
Recent correspondence from a government body / Signature
For patients from overseas – a passport or ID card
Birth Certificate

Created on 05/07/2016