New Patient Questionnaire Form - Welcome to Keats Group Practice

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Information About You

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

Medical Information

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Living Will & Lasting Power of Attorney for Health & Wellbeing

If you answer Yes, to the question below, please provide us with a copy to be held on your records.

Further information can be found on teh NHS website:

Advance decision (living will) - NHS (www.nhs.uk)

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

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

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

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. *

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

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

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New Patient Questionnaire - Updated

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New Patient Questionnaire - Updated

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