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