Dr Kidd & Dr Cosgrove                    NEW PATIENT HEALTH QUESTIONNAIRE

Please complete this form fully and sign before returning to the practice with supporting documentation. We will ask you to retain all forms until all information has been provided.    

Section A – Patient Details

Surname: …………………………………………  Forename(s): …………………………………..

DOB: …………………………………………….  Title: Mr/Mrs/Miss/Ms ………………………...

Known as: ………………………………………..  Male:          Female:  

Address: …………………………………………. ………………………………………………….

Post Code: ……................................... Tel. No. (Home): ……………….. (Work): ………………...

E-mail: ……………………………………………  Mobile: ………………………………………..

Next of Kin…………………………… Relationship to you:…………………………Tel:……………….

Section B

Past Medical History (i.e. Operations, Illnesses)
………………………………………………………………………………………………………………………………
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Current Medication
Are you currently on any regular medication? YES      ⁭   NO 	

Please also list current medication below:
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

Known Allergies
Do you suffer from any known allergies?  YES	           NO

Please also list all allergies below:
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

Family History  
Please circle where appropriate & state relationship & age

        Heart attack/Angina	         Yes / No	        Relation:                                 	         Age of onset:	
        Stroke	         Yes / No	        Relation:	         Age of onset:	
        High Blood Pressure	         Yes / No	        Relation:	         Age of onset:	
        Diabetes	         Yes / No	        Relation:	         Age of onset:	
        Glaucoma	         Yes / No	        Relation:	         Age of onset:	
        Asthma	         Yes / No	        Relation:	         Age of onset:	

Carer Status
Are you a Carer?  YES           NO 	      

Interpreter Service for Sign Language 

Do you require an interpreter service for sign language YES		NO

If yes, please provide details of interpreter service/person and contact details

Service………………………….Interpreter……………………………..Telephone/Email……………………….

Section C – (Registrations template)

Patient identified and checked against ID:  YES           Staff Member Name……………………..

Consent for Text Messaging

Are you happy for the practice to communicate with you by text message: YES      ⁭   NO 	

Health Promotion

Smoking Status: Never Smoked ⁭	    Ex-Smoker            Current Smoker 	No./day________

Do you drink alcohol?     Yes/No      Units/week: ……………………..
(1 Pint Beer = 2 Units; 1 Glass Wine = 1 Unit; 1 Measure Spirits= 1 ½ Units)

Do you take regular exercise? (times/week): ……………………………………………………….

Recordings (Home or at GP Surgery)

Date of Measurements…………………………….     Blood Pressure (if possible)…………………………………

Height………………………………….		  Weight. …………………………….

Ethnic Origin 
(Please tick one box):

 ⁭	White           Black African           Indian          Bangladeshi         Other (please state)  

 ⁭   	Black Caribbean       	Black Other Mixed      ⁭     Pakistani          Chinese	 

       ⁭I do not wish my ethnic origin recorded      

Occupation: ……………………………….

Patient living in nursing home  	      YES 	       NO

Patient living in residential home      YES                 NO

Section D 

Date of last cervical smear (females only)……………………………………

Hospital Outpatients

Details of any hospital outpatients you are currently attending: ……………………………………………………..

If you are currently attending any outpatient appointments please inform them of your new GP and if you have a new address.

Previous GP

Name & Address of Last Doctor: ……………………………………………………………………

Reason for Changing Doctor: ………………………………………………………………………..

Section E – Foreign Nationals Only

Is English your first language?		YES 		NO 		

Languages Spoken: …………………………………………………………………………………..
(Starting with most fluent)

Would you benefit from an Interpreter Service, if so which language? ……………………………

Nationality: …………………………………………………………………………………………..

Next of Kin in Country of Origin ……………………………………… Telephone ………………..

Contact in Northern Ireland (if not abroad) ………………………….  Telephone ………………

Section E – Asylum Seekers Only

If you are an asylum seeker please tick		

If you have a case worker please provide contact details

Name……………………………Organisation…………………………..Contact Number…………………..…

Section F – Patient Signature

I can confirm that the information that I have provided is true and accurate. 

Signed……………………………………………………….		Date……………………………..

For office use only		

Forms checked and verified by receptionist before accepting

If incomplete, forms to be returned to patient at time of presenting at practice	
 	Y/N/NA	Employee	Notes	
1. Forms 	 	 	 	
Registration form complete and signed	 	 	 	
Correct HS200/HSCR1 complete and signed with supporting documents (sec 13.1 – HS200)	 	 	 	
Medication list from previous GP provided (if yes leave for pharmacist)	 	 	 	
Allergies list from previous GP provided (if yes leave for pharmacist)	 	 	 	
Copy of red book if child provided 	 	 	 	
Carers form completed if applicable 	 	 	 	
				
2. Alerts	 	 	 	
Interpreter service for sign language required (if yes place alert on record with contact details)	 	 	 	
Language Interpreter Required (if yes please place alert on record with language)	 	 	 	
				
3. Complete Registration Coding and add next of kin to registration screen	 	 	 	
				
4. Put patient through Emis Registration Links	 	 	 	
				
5. Forms left in tray for GP to sign 	 	 	 	
				
6. Forms scanned to patient record once signed by a GP 	 	 	 	
				
7. Records sent to BSO via email	 	 	 	
           HS200 NI Resident -  Hold	 	 	 	
           HS200 GB – send to BSO	 	 	 	
           HSCR1 – send to BSO	 	 	 	
				
8. Place note on registration links when has been emailed to BSO. (Date and initial)