Old Bridge Surgery

01503 266960

New Patient Health Questionnaire – Adult

The doctors and staff welcome you to the Practice. In order for us to provide you with good quality care it would be helpful if you could complete the questionnaire below to provide us with some information regarding your personal details and your medical history.

Please note that you will still be required to bring 2 forms of I.D. down to the surgery to complete your registration. (We require photographic I.D. and proof of address i.e. passport and utility bill).

  • Personal Details

  • DD slash MM slash YYYY
  • (By providing my home number I consent for Old Bridge Surgery to use it to contact me).
  • (By providing my mobile number I consent for Old Bridge Surgery to use it to contact me).
  • (By providing my work number I consent for Old Bridge Surgery to use it to contact me).
  • (By providing my e-mail address I consent for Old Bridge Surgery to use it to contact me).
  • (If you require a translator to attend your consultations then please notify reception)

  • Next of Kin Details:

  • Carer Registration

    If you care for, or help someone with an illness or disability, whether this is a partner, friend, other relation or even a neighbour then you are a CARER.

  • General Information

  • (Including the contraceptive pill)
  • (Please bring down to the surgery a repeat slip if possible)

  • Women Only

  • MM slash DD slash YYYY
  • Please select from the list below.
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY

  • Medical History

  • Family History

    Please tick below the current health status and medical history of your first degree relatives.

Date published: 18th July, 2017
Date last updated: 24th August, 2017