The Castle Practice New Patient Questionnaire
Thank you for choosing our surgery. As part of your registration, please take a few moments to complete the questions below.
Once completed, please give this to reception with the following documents:
NHS Registration form
Two forms of identification, one to confirm identity and one to confirm residency
Health visitors form if you have children under 5 years old
At the same time, please book your new patient health check
You will need to bring a sample of urine with you
Your FirstName:Your Family Name:
Are you an Armed Forces veteran? Yes No
Ethnicity
It is not compulsory to tell us your ethnic origin and it will not prejudice your healthcare. However, some health problems are more common in specific communities and knowing your origins may help with the early identification of these conditions.
Please tick below to indicate your background:
White British Indian
Irish Pakistani
Other white (e.g. European) Bangladeshi
White & Black Caribbean Other Asian background
White & Black African Chinese
White & Asian Caribbean
Other Mixed background African
Other than listed above I do not wish to state
Smoking (cigarettes, pipe, cigars, shisha)
Do you smoke?YesNo
If no:Did you give up over 10 years ago
Or
Have you never smoked?
Would you like support to give up smoking? (We have Stop Smoking Advisors) Yes No
About Contacting You
Patients have found it helpful to receive SMS text reminders of appointments
If you are happy for us to do this, please write your mobile number here ______
N.B. The parents / guardians of children aged 11 or under may use SMS messaging to be reminded of children’s appointments.
Very Occasionally we send out email newsletters or questionnaires to patients to help us improve the service that we offer. If you are happy to receive these, please indicate your email address below. Please be aware that we will not answer queries about your health via this method as we do not feel emails offer enough confidentiality. Although emails are generated using a secure facility they are transmitted over a public network onto personal email accounts and, as such, may not be secure.
About your Information
Your data is confidential. However, there are three ways that this may be shared:-
- When we make a referral for you to see another clinician, for example a consultant at the hospital, we will include the medical information that they need to make a diagnosis and treat you.
- The Summary Care Record – we automatically share your allergies and recent medication with emergency practitioners such as the Ambulance services, Out of Hours doctors or Accident & Emergency. This could save your life. If you do not want us to do this, please tick the appropriate box:
- Care Data- The government would like anonymised information about you to be available to researchers, so that they can know more about how diseases affect people, or to develop medication for etc. This information does not benefit you directly as a patient. It is your decision whether you want this to happen
I do not want my data to be shared
For Your Convenience
I would like to be able to arrange appointments on line Yes No
I would like to be able to order my medication on lineYes No
If your answer to either question above was “yes”, we will need your email address to send you a confidential username and password.
My email address is: ______
Carers
Do you have a carer or support assistant?Yes No
If yes, please give the name and contact details for your carer: ______
Your carer may be a member of the family or a friend, or someone paid to help you – e.g. helps you to get up or go to bed, helps with your medication etc.
Are you a carer?Yes No
Definition: A carer is a person who provides unpaid support to a family member or friend, e.g. with dressing, cooking, shopping, without which they would be unable to look after themselves.
If yes, please give the name of the person you look after: ______
Do they live at the same address as you? Yes No
As far as you know, are they registered at this surgery? Yes No