New patient questionnaire (adult)

Welcome to the Nuffield Practice

New patient questionnaire (adult):
Please help us by completing the following information. This is very important as it may take some weeks for your medical records to arrive.

Patient's Details - Please complete the text boxes and tick where appropriate

Surname is required
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Forenames is required
Calling name is required
Title is required
Sex is required field
Date of birth is required
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Address is required
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Telephone numbers:

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How often do you exercise?

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(please use the scales in reception if you haven’t weighed yourself recently)

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(please use the blood pressure machine. The receptionist will show you how) Invalid Input

Next of kin:

Name is required
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Address is a required field
Relationship is required field
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Would you like to give up smoking? Help and treatment is available here-ask at reception

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If you are on any regular medication, please bring in a repeat prescription slip from your old practice, listing your medication, so that we can put it on the computer. Otherwise, you will have to have an appointment with the doctor before we can give you a prescription. Please allow plenty of time for your prescription to be prepared: we need at least 2 working days for your prescription to be authorised and sent to the pharmacy (and the Pharmacies need another 2 working days for dispensing.)

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If you have a Dossett Box then please ensure you have adequate medication as it can take 6 weeks to organise.

Do you have any allergies to any medicines or substances on your skin?

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Ethnicity:

Please tick the ethnic group which you feel most accurately describes you. These are National codes as defined by the 2001 Census.

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Language:

What is your first language? Please tick. For babies and children please tick the language of their parents.

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FAST alcohol screening:

Pint of regular beer/lager/cider

Alcopop or can of lager

Glass of wine (175ml)

Single measure of spirits

Bottle of wine

2 units

1.5 units

2 units

1 unit

9 units

If you are 16 or over, please complete the following questions

Questions:

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Only answer the following questions if your score is 2 or more

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Scoring: a total of 3 or above indicates hazardous or harmful drinking.

If you scored 3 or more and are interested in finding out a bit more, please ask the receptionist for the longer alcohol audit questionnaire and leaflet.

Practice use only:

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Thank you for completing this form.

Are there any other members of your family to be registered?

Please ask for a practice leaflet which tells you about our services.

Further information

Call 111 Logonhs choices

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