The Bydand Medical Group

BBC | Health News

New Patient Questionnaire - Under 16's | Over 16's - (For new patients wanting to join the practice)

Fields marked with a * are compulsory.

* Name: * Date Of Birth:  
* Address:
Telephone:
* Email Address:
* Repeat Email:
    Contact Number:
(If different from above)
* Name of Parent/Gaurdian:
Which ethnic group do you belong to? - You are not obliged to complete this section.
Please tick as appropriate
White 9S1 Chinese 9S9 Indian 9S6 Bangladeshi 9S8
Pakistani 9S7   Black-African 9S3   Black Caribbean 9S2   Other - please state
I do not wish to give this information  
Medical History  
Previous Serious Illness Operations   Dates
     
     
Present regular medication (please list name, strength and how often taken)
Name Strength How Often Taken
1: 1: 1:
  2:   2:   2:
  3:   3:   3:
Drug Allergies
1: 3:
  2: 4:
Smoking Habits (for over 14 years only)      
Smoker Number of cigarettes/ cigars/ tobacco per day Non-Smoker
Immunisations (must be completed where possible)
Immunisations Age Normally given Date of Immunisation
Diptheria, tetanus, whooping cough, polio & Hib 2 months 1st dose
3 months 2nd dose
4 months 3rd dose
Meningitis C 2 months 1 dose
3 months 2nd dose
4 months 3rd dose
MMR 13 - 18 months  
Booster dose Diptheria, tetanus, polio, MMR 4-5 years
Other Immunisations (please list below)
Immunisation   Date   Immunisation   Date  
 
 
 
I understand that email cannot be guaranteed as totally secure and confidential. The Practice cannot take responsibility for any problems arising through the use of this on-line request. Tick the box below to accept these terms and conditions and then submit your request.
I accept the terms and conditions above
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