New Patient Questionnaire for under 16s

Please be advised that it can take a considerable time for your medical records to reach us. The information required in this form is required in order to help us better facilitate your immediate needs and will be treated with the strictest confidence.

New Patient Supplementary Questionnaire Under 16s
Please use format day/month/year e.g. 12/05/2018
Gender
Please detail as much of your medical history that you feel will help us better facilitate your immediate medical needs. Include: previous serious illnesses and dates of significant operations
Please detail any current medication that you are currently prescribed including: name, dosage, and how often taken
Please list any drug allergies that you have
Please let us know of anyone in your family for whom has a history of: Heart disease, Stroke, Cancer, or diabetes
Smoker?
How many cigarettes do you smoke in a day? If you are an ex smoker how many cigarettes did you smoke in a day?
Immunisations
Please select all immunisations that you are aware you have had
Please let us know of any additional immunisations that you are aware of having
Any other information that will help to better inform the GP of your medical needs?
GP’s name and the name and address of your previous GP medical practice
Consent to contact your previous medical practice
We will have to contact your previous medical practice in order to have an up-to-date record of your current medical needs. Please indicate your consent for us to do this
Consent