Meopham Medical Centre
Patient Registration Form
Are you filling this form for yourself
*
Yes
No
Relationship to Patient
Full Name
*
Mr.
Mrs.
Ms.
Miss.
Mstr
Mx
Dr
Prefix
First Name
Last Name
NHS Number (if known)
Date of Birth
*
-
Day
-
Month
Year
Date
Identified Gender
*
Male
Female
Non-Binary
Not Specified
Ethnicity
Please Select
White - English, Welsh, Scottish, Northern Irish or British
White - Irish
White - Gypsy or Irish Traveller
Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other Mixed or Multiple ethnic background
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Asian - Chinese
Any other Asian background
Black - African
Black - Caribbean
Any other Black, African or Caribbean background
Other - Arab
Any other ethnic group
Were you born in the UK?
*
Yes
No
If No, please enter your country of birth
*
Date of entry into the UK
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
Town
County
Postal Code
Landline Number
-
Area Code
Phone Number
Mobile Number
*
-
Phone Number
Email address
*
example@example.com
Confirm Email address
*
example@example.com
Previous Address If New To Area
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you happy for us to communicate with you via SMS text and/or email? THIS WILL NEVER BE USED FOR MARKETING.
*
Yes to Both
Yes to SMS text
Yes to Email
No to Both
Have you previously been registered with a GP in England?
*
Yes
No
Please entre the name of your previous GP Practice
Do you have any ongoing medical conditions?
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
History of Mental Health , including Depression and Anxiety
Epilepsy
Other
No ongoing medical conditions
If other please list below
Do you have a Family History of any medical conditions?
*
Yes
No
Check the conditions that apply to you or to any members of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
History of Mental Health
Epilepsy
Other
Do you use or do you have history of using tobacco?
*
Please Select
Never smoked
Current Smoker
Ex-Smoker
What do you smoke?
Please Select
Cigarette smoker
Tobacco smoker
Pipe smoker
Rolls own cigarettes
Cigar smoker
Would you like help to quit?
Please Select
Yes
No
How often do you consume alcohol?
*
Never
Monthly or less
2/4 times/month
2/4 time/week
4+ times/week
How many units of alcohol do you drink in a typical day, when drinking?
1-2 units
3-4 units
5-6 units
7-9 units
10+ units
How often do have you had 6 or more units (female)/8 or more (male) on a single occasion in the last year?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Are you caring for a family member
Please Select
Yes
No
Are you currently at University
Please Select
Yes
No
If yes, where are you studying?
Are you happy with your key health information being shared with other health professionals in case of an urgent or emergency situation?
*
Please Select
Yes
No
Would you like access to online services; view medical history, blood tests and order repeat medication?
Please Select
Yes
No
Next of Kin
Name
*
Prefix
First Name
Last Name
Relation
*
Are they already registered at Meopham Medical Centre?
*
Please Select
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Are you happy for your records to be discussed with your Next of Kin?
*
Please Select
Yes
No
Submit
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