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HOW TO REGISTER You can register with the practice either privately or as an NHS patient. At the time of registration we ask you to complete the following questionnaire giving us relevant details until your medical record arrives (normally within six weeks). The Practice Manager can provide details of our fee scale when registering privately.
Date of Birth............................................................. Male / Female Single / Married Address..................................................................... Tel No Home ..................................... .................................................................................
Work ...................................... Occupation
.............................................................. Please list any serious illnesses, accidents, operations or
disabilities:- 1) ............................................................................................................................................... 2)................................................................................................................................................. 3)................................................................................................................................................. FAMILY HISTORY Please indicate any significant illnesses in your immediate family (such as heart disease, stroke, asthma, diabetes, epilepsy etc Mother ....................................................................................................................................... Father ........................................................................................................................................ Brothers ..................................................................................................................................... Sisters ........................................................................................................................................
Please list any medicines you take regularly including their frequency:- 1) ................................................................................................................................................ 2) ................................................................................................................................................ 3) ................................................................................................................................................
Please state any substance to which you may be allergic - .........................................................
Height .................................................. Weight ................................................... Do you smoke?
YES NO
NEVER How many units of alcohol do you drink on average each week? (1 unit = 1/2 pt beer or 1 glass wine or 1 measure spirit) .............................. units alcohol/week
Are you taking the contraceptive pill? YES / NO Are you fitted with a contraceptive ‘coil’? YES / NO Have you ever had a cervical smear? YES / NO Date of last cervical smear ..........................
Thank you for completing this form - it will remain confidential.
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