New Patient Questionnaire - Trinity Medical

Last Updated: 10/06/2024

Your Contact Details

Title

Name *

Previous Surname

Date of Birth *

Address *

Postcode *

Home Number

Mobile Number

Work Number

Email Address

Preferred method of contact

Telephone

Text

Information About You

Previous GP

Name and Address of Previous GP *

Proof of Identity and Address Provided

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Job History

Do you currently work?

Yes

Retired

Other

If yes, what is your job

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

To be completed by Female patients only

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Will

Do you hold a Living Will? *

Yes No

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you have stopped smoking, when did you give up?

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

Please give name of your next of kin

Please specify their relationship to you

Please provide contact details for your next of kin

Vaccinations

Have you had a flu vaccination? *

Yes No

If yes, enter date of your latest flu vaccination

Have you had a pneumococcal (pneumonia) vaccination? *

Yes No

If yes, enter date of your latest pneumococcal vaccination

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Do you want to register for on-line services? *

Yes No

Which Pharmacy would you like your prescriptions to be sent to? *

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

Yes No

Signature

Signature *

Date *

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New Patient Questionnaire - Trinity Medical

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