TMG New Patient Questionnaire

Welcome to the Practice. Please help us by completing this questionnaire. Any information given is strictly confidential. It is collected to ensure that we treat all patients fairly and equally. It gives us the opportunity to meet all your needs both physically and emotional.

Last Updated: 15/07/2022

Personal Details

Title

Gender

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number (Inc Area Code)

Mobile Number

Email Address

Access Instructions (Key Safe etc.)

Do you have any communication / information needs relating to a disability, impairment or sensory loss? If so, please provide details:

What To Do Next

If you have not already done so, please submit a Patient Registration Form. This form IS NOT a registration form and is to help us gather information for new patients,.

Personal History

Have you ever suffered from any of the following conditions? If anyone in your family suffers with any of the following, please provide details below.

Diabetes - If yes, give details (year of diagnosis / type / treatment)

Stroke or TIA (mini stroke) - If yes, give details (year of diagnosis / type / treatment)

Cancer - If yes, give details (year of diagnosis / type / treatment)

Chronic Kidney Disease - If yes, give details (year of diagnosis / type / treatment)

Asthma - If yes, give details (year of diagnosis / type / treatment)

High Blood Pressure - If yes, give details (year of diagnosis / type / treatment)

Mental Health Conditions e.g. bipolar, schizophrenia etc. - If yes, give details (year of diagnosis / type / treatment)

Other (including significant operations) - If yes, give details (year of diagnosis / type / treatment)

Heart Attack/Angina - If yes, give details (year of diagnosis / type / treatment)

Allergies

Are you allergic to any medication? If yes, please give details of medication and reaction:

Are you allergic to any other substances e.g. nuts, other foods? If yes, please give details of substance and reaction:

Medication

Smoking

If you are a smoker and have the desire to stop please visit www.nhs.uk/smokefree for a wide range of free support or ask for further information at reception or your local pharmacy.

Please inform us of your current Smoking Status *

Never Smoked

Cigarette Smoker

Roll-up Cigarette Smoker

Cigar Smoker

Pipe Smoker

Ex-Smoker

Electronic cigarette Smoker

If you are an ex smoker what is the date you gave up

How many cigarette/cigars/grams per day do / did you smoke?

Are you considering stopping smoking?

Yes No

Your statistics

What is your height? *

What is your weight? *

What is your blood pressure? (Please use the Blood Pressure machine available in the Practice)

Alcohol

How many units of alcohol do you drink per week? *

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Military Veteran

ARE YOU A MILITARY VETERAN? *

Yes No

IF YES, PLEASE TICK ONE OF THE BOXES BELOW:

Military Veteran

Army Veteran

Royal Air Force Veteran

Royal Marines Veteran

Royal Navy Veteran

SERVICE NUMBER:

ENLISTMENT DATE:

DISCHARGE DATE (IF APPLICABLE):

Next of Kin

It is very helpful to have your next of kin or contact details but we are required to obtain consent before we can include them on your medical records. Please ask your chosen next of kin contact to complete this section.

Please give name, address, telephone number and relationship of next of kin *

I agree that my contact details can be added to the above medical record and that I can be contacted in an emergency. Signed Consent of Next of Kin.

Carers

If Yes to either of the below please ask our receptionist for a “Tell Your GP You Are a Carer” form.

Are you a carer? *

Yes No

Do you have a carer? *

Yes No

In Case of Emergency

Do you have a nominated person in case of an emergency? If details have not already been provided on this form we are required to obtain consent before we can include them on your medical records.

Please give name, address, telephone number of emergency contact

I agree that my contact details can be added to the above medical record and that I can be contacted in an emergency - signature

Equity of Access Information

This information is asked to ensure that every patient is treated equally and fairly. If you would prefer not to answer any of these questions please tick the ‘do not wish to complete’ box.

Patient Email Group (PEG) / Patient Participation Group (PPG)

We want to ensure our patients are involved in the decisions about the range and quality of services provided by the practice. This can be done as a PEG (email) or in person (PPG). See website for further details www.tyntesfield.nhs.uk

I am interested in joining... *

I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

PEG (please provide email address)

PPG

Email address

Data Systems

You can find more information about our data systems and policies on our website. You can opt out of your data being transferred out of the Practice for any of these schemes. If you wish to opt out of any of the above please tick the relevant options, sign below and hand the form to reception.

Opt out options

I wish to opt out of my data being uploaded to the national ‘Summary Care Record’

I wish to opt out of the local ‘Connecting Care Record’

I wish to opt out of the ‘Local Record Sharing’

Date *

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TMG New Patient Questionnaire

Further Information