NEW PATIENT QUESTIONNAIRE - The Surgery @ Wheatbridge

Current health
Please help us with some baseline facts about your health.
Height __________________ Last Cholesterol (if over 40) ________
Weight _________________ Last BP (Max/Minimum) _____ / ______
If you would like to check blood pressure, help yourself – and please
record it here. Our check-it-yourself blood pressure monitor (for adults)
is located in the waiting room on the first floor.
Alcohol intake _______ units/week
If you smoke, medical advice is to cut down or stop – though this isn’t
always easy. Please tick Never smoked [ ] Ex smoker [ ]
(Quit date) ____/_____/_____
Currently smoke (type) ______ (amount per week) ____ (Or day)______
If you would like help stopping, ask a receptionist for an appointment
with a Smoking Cessation advisor here at the surgery.
We offer new patient health check appointments with our practice
nurses. If you consider yourself fit and well and wish to decline this,
please tick here – [ ]. If you would like to see the nurse, please ask a
receptionist.
Exercise is healthy for most people, though some should take medical
advice first. Please let us know -
What exercises do you enjoy, and for how long per day or week?
________________________________________________________
Have you been advised to avoid heavy work or exercise? What was the
reason? __________________________________________________
If you struggle to walk outside on your own more than 50 yards or
metres on the flat, or more than 5 minutes without stopping, please
consider a new patient health check appointment with a nurse or GP.
Early Diagnosis, Screening and Prevention
We offer a full range of Enhanced Services and Screening
recommended by the local Primary Care Trust, the Chief Medical Officer
and the Department of Health. You may receive letters inviting you to
book in for these if they apply to you. If you wish to “opt- out” of
particular preventative services and letters, please write to us.
That’s it! Now please hand this in with the purple form at reception.
Thank you.
NEW PATIENT QUESTIONNAIRE
Welcome to The Surgery @ Wheatbridge. Please complete this
form and the purple registration form you should have been given
from reception to register here. (Note if you downloaded this form
online, you need to complete a GMS1 form at the same time ).
The Surgery @ Wheatbridge offers National Health Service
personal medical services through General Practitioners, Nurses
and other staff. The practice offers some private services like
medical reports and travel health vaccination.
The building also provides a site for other people like district
nurses, physiotherapists, a pharmacist, health visitors, podiatrists,
dentists, sexual health clinics and others. If you are looking for
these other services, rather than General Practice, please ask for
directions from our receptionist.
Our practice area – we cover: Old Whittington, Newbold Moor,
Whittington Moor, Tapton, Hasland, Wingerworth, Birdholme,
Boythorpe, Walton, Holymoorside, Brookside, Old Brampton,
Loundsley Green, Upper Newbold and Dunston. We don’t take on
people who live outside our area - we may not get to you in a
timely way if you were too sick to get out.
So you live in our area and are planning to stay. Next, we’d like to
find out a bit more about you so we can get in touch if necessary.
You can ask for a pen at the reception desk. Please print or write
in capitals. We take confidentiality seriously.
We send appointment reminders VIA text message to all
patients who have a mobile number registered to them,
please keep your mobile number up to date.

Preferred Title (Mr Ms Mrs Miss (Other Please Specify)____________
Marital Status____________________________________
Your full name ___________________________________________
(As on your birth, marriage certificate or passport)
Preferred, first, calling name _________________________________
Date of birth (DD/ MM/ YYYY) _____________________
Ethnic background (some health problems may be inherited)
________________________________________________________
First Language (if other than English) ________________________
Telephone number______________________________________
Mobile Telephone number
(We will use this to automatically text you reminders of your appointments unless
you inform us that you decline)
____________________________________
Please tick if you wish to Decline text reminder service? [ ]
Email address __________________________________
House Number (Name) and Street ____________________________
Town _____________________________Post code ______________
Next of Kin or someone to contact In case of emergency.
Name / Relationship _______________________________________
Best Contact number: _____________________________________
Address ___________________________________________
___________________________________________
___________________________________________
Your old medical notes may take some time to arrive from your last
doctor. Please ensure you complete the following
Any ALLERGIES or SENSITIVITIES or PROBLEMS– with tablets,
medicines, powders, injections, inhalers, vaccines, foods, animals,
plants or minerals.
Source Reaction
______________ __________________________________
______________ __________________________________
______________ __________________________________
Repeat Prescriptions
If you have any repeat prescriptions for regular medicines from a
doctor, please bring in your previous prescription or medication packets
for our prescriptions team. The doctor will review this and update your
medication on the computer. We are very careful to get medicine names
correct, so our receptionists are instructed not to process prescription
requests over the telephone. Please allow us two full working days to
process prescription requests/ please ask at your local pharmacy if you
wish to use their collection services.
Treatments
Some people have strong beliefs that mean they refuse certain
treatments in certain situations. (Such as blood transfusions) If this
applies to you, please tell us here
Treatment refused Treatment for
___________________________/_____________________________
It can take up to eight weeks for us to get your medical records
Please let us know of any relevant medical history within the last 12
months
Operations / Hospital stays / Conditions Month began
Disabling condition needing treatment, time off or carers Year began
Are you employed / unemployed? (Delete appropriate) other _________
Are you a carer for someone? Yes / No
Any Relevant Family History (e.g. Diabetes / Heart Disease)
What attracted you to this surgery? ____________________________
Women Only
Date of your most recent smear? _________/_________/__________
What form of contraception do you use? _______________________