Elswick Family Practice - New Patient Registration Questionnaire (Adult: 16 Years old and over)

New Patient Registration Questionnaire(Adult: 16 Years old and over)
Patient Details*

MrMrsMissMsOther
Name*

First NameLast Name
Previous Surnames/Maiden Name
Date of birth*

DayMonthYear
Date
NHS No (if known)
Gender*

MaleFemaleOther
Home Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Mobile Phone Number*
Home Phone Number*
Email Address*
example@example.com
Are you currently employed*

Full-TimePart-TimeSelf-EmployedUnemployed
Which best describes you*

RetiredStudentHousewife/Househusband/homemaker/other
Your first choice of contact*

LetterEmailTextPhone
Ethnicity*

White EnglishWhite Northern IrishWhite ScottishWhite WelchWhite CypriotWhite GreekWhite Greek CypriotWhite TurkishWhite Turkish CypriotWhite ItalianWhite PolishWhite KosovanWhite and Black CaribbeanWhite and Black AfricanWhite and AsianBangladeshi/British BangladeshiBritish AsianIndian/British IndianBlack BritishBlack CaribbeanBlack AfricanBlack NigerianBlack SomaliChineseJewishIranianArabLatin AmericanNorth AfricaOtherI do not wish to disclose
What is your second language? (If applicable)
Do you need an Interpreter?*

YesNo
Please choose your religion*

Church of EnglandCatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah's WitnessNo ReligionPrefer not to say
NHS Regulations 2015 Self-Declaration*

I am a British resident and entitled to full NHS careI hold a non-UK issued European Health Insurance Card (EHIC)I hold an S1 form (entitled to health care in another European Economic Area country for a limited duration)
Next of Kin
Next of kin full name*

First NameLast Name
Relationship to Patient*
Contact Phone Number*
Carers
Are you a carer for someone who is ill, frail, disabled, has substance problems or has mental health needs?*

YesNo
Do you have a carer?*

YesNo
Are you housebound*

YesNo
Do you need help with mobility/hearing/speaking?*

YesNo
Medical Records
Please help us trace your previous medical records by providing as much of the following information as possible:
Your previous address in the UK

Street Address

Street Address Line 2

CityCounty

Postcode
Name of previous Doctor while at the address
Address of previous doctors

Street Address

Street Address Line 2

CityCounty

Postcode
If you are returning from armed forces
Address before enlisting

Street Address

Street Address Line 2

CityCounty

Postcode
Service or personnel number*
Enlistment Date

DayMonthYear
Date
Should be Empty:

New Patient Registration Questionnaire(Adult: 16 Years old and over)

Next of Kin

Carers

Medical Records

If you are returning from armed forces