New Registration Form

1) Personal details

Title  
Surname (Family Name)
 
First Names (Forenames)
 
Previous surname
 
Date of birth ( dd / mm/ yyyy )
 
Male / Female  
Marital Status  
Telephone
  (mobile)
(home)
Email address
 
Do you have any children ?  

No
Yes How many / year(s) born
(e.g. 3 children M 1995, F1998, M 2000)

Your CURRENT address in London
Flat Number  
House Number & Road / Street  
Post Code  
Do you need an interpreter ?   No       Yes
Your main spoken languages  
Ethnicity  
Religion  
     
Your NHS number (if known)  
Town of Birth  
Country of Birth  
(If you were born outside the UK)
Date of entry to the UK.(DD / mm / yyyy)
 
Name of your next of kin (someone we can contact in an emergency)  
Contact number of your next of kin  
Next of kin's relationship to you  
Is any member of your family registered with our practice ?  

No

Yes Name and surname of family member
registered with our practic
e

Have you ever been registered with an NHS doctor before in the UK ?   No
Yes Name of surgery if known
     
Your PREVIOUS address in the UK (if you had one, leave blank if this is your first address)
Flat Number  
House Number & Road / Street  
Town and Post Code   Town             
Post Code
     
Are you caring for or helping to care for an ill person, friend, neighbour? If yes, please give details   No
Yes
Details
Profession / Job /  

2) Questions about your health

Do you smoke ? (If you smoke cigars or a pipe, please say so in the comments box)  

No
Yes How many cigarettes / day ?     
Would you like help to give up smoking ?
Other comments
   

Are you an ex-smoker ? (If you used to smoke cigars or a pipe, please say so in the comments box)  

No
Yes How many cigarettes / day ?     
When did you stop smoking ?                
Other comments
    

Do you drink any alcohol ?  

No
Yes Units / week
(A unit of alcohol is 180 ml / a third of a pint of beer, a small glass of wine, or a UK pub size shot of spirits)
Other comments

Do you use any other drugs ?  

No
Yes Details (If you would rather not write this, please let the nurse know during your health check)

What kind of exercise do you do ?  

How often do you take exercise ?  
     
Males Only    
Have you had any information about testicular self examination ?   If you would like more information, please click here or discuss this with one of our nurses during your registration health check
Females Only    
Do you know about breast awareness / self-examination ?   If you would like more information, please click here or discuss this with one of our nurses during your registration health check
Will you need a prescription for the contraceptive pill at your health check appointment ?   No
Yes
Have you had a smear / Pap test ?   No
Yes        Date of last test
Result of last test                  
Country where test was done
Other comments
Have you ever had a mammograme ? (an x-ray of the breast that is designed to detect breast cancer, normally for for women aged 50 to 70 yrs)   No
Yes Date of last test        
Result of last test                   
Country where test was done
Other comments
Have you ever taken Hormone Replacement Therapy ?
  No
Yes Details
 

The following sections should be completed by all patients

Your Past & Present Health History
  Do you or have you ever suffered from any of the following:?
If yes, please click YES and give any relevant details and the date/year of the event
Asthma/COPD
  No
 Yes Details
Cancer   No
Yes Details
Depression   No
Yes Details
Diabetes   No
Yes Details
Fractures / broken bones   No
Yes Details
Glaucoma   No
Yes Details
Heart Disease   No
Yes Details
Hepatitis   No         
Yes Details
High blood pressure   No         
Yes Details
High cholesterol   No         
Yes Details
Operations / surgery   No         
Yes Details
Any mental illnesses   No         
Yes Details
Stroke / TIA   No         
Yes Details
TB   No         
Yes Details
Other illnesses   No         
Yes Details
     
Allergies    
Are you allergic to any medications ?   No
Yes Details
Are you allergic to anything else ?   No
Yes Details
Childhood diseases - please tell us which diseases you have had, and approximate year
Chicken pox   No
Yes Year
Measles   No
Yes Year
Mumps   No
Yes Year
Other (please provide basic details and year)  
Vaccinations    
Have you been vaccinated against the following: If yes, please give date / year of most recent dose
   
Tetanus   No
Yes Date last dose
Polio   No
Yes Date last dose
Rubella   No
Yes Date last dose
Pneumococcal   No
Yes Date last dose
Please add any other information about your health in the box apposite  
     
3) Your Family Health History
Has your mother, father, sisters, brothers, grandparents suffered from any of the following( If yes, please click YES and give any relevant details (i.e. which family member). We don't expect you to email them all with this form - let us know what you know, and we can always update your details in future if required.:
     
Asthma/COPD
  No
Yes Family member(s)
Cancer   No
Yes Family member(s)
Depression   No
Yes Family member(s)
Diabetes   No
Yes Family member(s)
Glaucoma   No
Yes Family member(s)
Heart Disease   No
Yes Family member(s)
Hepatitis   No
Yes Family member(s)
High blood pressure   No
Yes Family member(s)
High cholesterol   No
Yes Family member(s)
Any mental illnesses   No
Yes Family member(s)
Stroke / TIA   No
Yes Family member(s)
TB   No
Yes Family member(s)

If there is any other information (about anything !) you would like to add, please do so in the box below. We can amend any of the details at any time, so don't worry if you don't know all the information requested at this time..

4) Disclaimer - Please Read

Please note that this detail within this form is not encrypted but is as safe and confidential as any other method of sending us your repeat requests. Please confirm that you are willing to accept this and use this service by clicking the accept box below. If you do not wish to use this form then please click the "Clear Form" button.

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