New Patient Health Questionnaire

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Marital Status: *

Pronouns: *

Previous Details

Were you born in the UK?:

What Is Your Ethnic Group?

Choose ONE section from A to E.: *

Tick the appropriate box to indicate your ethnic group:

Carers

Are you a carer?: *

Do you have a carer?: *

Allergies

Do you have any allergies?: *

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Personal Health History

Immunisations and dates::

Do you have any of the following/have had the procedure:

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

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Health Habits And Personal Safety

Exercise: *

Are You Dieting?: *

Are you on a doctor prescribed medical diet?:

Do You Smoke?: *

Are You An Ex-Smoker:

Do you drink alcohol?: *

How often do you have a drink that contains alcohol?:

How many standard alcoholic drinks do you have on a typical day when you are drinking:

How often do you have 6 or more standard drinks on one occasion?:

Please note that a total of 5+ indicates hazardous or harmful drinking and we would advise that you make an appointment with a doctor or a nurse at the practice to discuss this

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Family Health History

Please complete below to indicate if any of your family have had any of the following

High Blood Pressure:

Heart Problems:

Diabetes:

Cancer:

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Next Of Kin

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Patients Aged 65 And Over Or Those With A Chronic Disease (e.g. asthma or diabetes)

Have you had a ‘flu’ vaccination?:

Have you had a pneumococcal vaccination?:

Have you had 2 or more doses of COVID-19 Vaccination:

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GDPR Consent

I give consent to be contacted by the surgery by SMS text: *

Do you require communication by a different method: *

I give consent to be contacted by the surgery by email: *

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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

SCR Options:

If you do not return this form, a Summary Care Record will be created for you based on implied consent

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Addington Medical Practice
Parkway Health Centre
New Addington
Croydon
Surrey
CR0 0JA

CONTACT VIA EMAIL

Telephone: 01689 849 993
Out-Of-Hours: 111

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Addington Medical Practice
7 Gravel Hill
Addington
Croydon
Surrey
CR0 5BG

CONTACT VIA EMAIL

Telephone: 020 8655 4013

VETERAN FRIENDLY PRACTICE

Armed Forces veteran friendly accredited GP practice

PRIDE IN PRACTICE

This practice has been awarded Gold for excellence in lesbian, gay, bisexual and trans healthcare

Addington Medical Practice

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New Patient Health Questionnaire

Summary Care Record (SCR)

Privacy Consent

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VETERAN FRIENDLY PRACTICE

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