New Patient Registration Form – Adult Patient's Details Title * Mr Mrs Miss Ms Surname * Date of Birth * First names * NHS Number Previous surnames Gender * Male Female Town and country of birth * Home address * Postcode * Email address * Home telephone number Mobile telephone number Please help us trace your previous medical records by providing the following information Your previous address in UK Name of previous doctor while at that address Address of previous doctor If you are from abroad Your first UK address where registered with a GP If previous resident in UK, date of leaving (month/year) Date you first came to live in UK If you are returning from the armed forces Address before enlisting Service or personnel number Enlistment date If you need your doctor to dispense medicines and appliances Not all doctors are authorised to dispence medicines Dispensing I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist Signature * Date * Personal Information Occupation Do you wish your next of kin or any significant other to be able to access and discuss your medical information on your behalf? Yes No Next of Kin name Relationship to you Contact telephone number Special Circumstances Are there any special circumstances that you would like to being to our attention? (e.g social circumstances, housing concerns etc) Yes No Please give details Has anyone in the family been known to social care or had a Social Worker? Yes No Please give details Language Is English your first language? Yes No Please state language Your Country of Origin Ethnicity Ethnicity Group White British Other White Mixed Asian Pakistani Asian Bangladeshi Other Asian Black British - Caribbean Black British Other Black Chinese Other Health Height Weight Blood Pressure Do you, or have you ever smoked? Smoker Never smoked Ex-smoker Date of quitting Female Patients Have you had a cervical smear? Yes No What year Result Have you had a hysterectomy? Yes No What year Carers Do you care for someone with a disability or illness? Yes No If you have a disability or illness, do you have a carer? Yes No I need a carer Immunisations If you are unsure whether your immunisations are up to date, please book an appointment for a consultation with a nurse. Current Treatments/Illnesses Please select all that apply: Long term lung disease Asthma Heart disease High blood pressure Depression Irregular heart beat Diabetes Liver disease Dementia Mental health issues Are you under hospital treatment for any condition? Yes No Please give details Have you attended A&E in the last year? Yes No Please give details Are you on any regular medication? Yes No Please give details If you are on long term medication for any medical condition you will initially need to see a doctor to obtain a prescription. Signature * Date *
