New patient health questionnaire

1 Your details

2 Contact details

3 Information to help us plan your care

Please provide a recent medication list and any vaccination records you have. If relevant, include recent hospital letters, care plans or a service medical summary. Copies are helpful, but do not delay registration if you do not have these documents.

You can bring copies to reception or email them to us. Please put your name and date of birth in the email.

Details of your previous GP, previous address and any overseas registration information should be provided through the NHS registration process or PRF1.

4 Keeping in touch safely

May we contact you about your healthcare using the details above?

5 Language and accessibility

6 Emergency contact

Naming an emergency contact does not give them automatic access to your medical records. If you want someone to discuss your care or use online services on your behalf, please ask us to arrange this separately.

7 Carers and other support

8 Allergies and reactions

9 Current medicines

Include prescribed medicines, inhalers, creams, contraception, medicines bought without a prescription and supplements. You can attach a recent medication list; note any changes and medicines prescribed by a hospital or private clinician.

10 Medical history and ongoing care

11 Children under 18

Complete this section if the patient is under 18. Otherwise go to section 12.

For children and young people, we will discuss confidentiality and any access to records separately, taking account of their age, understanding and circumstances.

12 Vaccinations for all ages

Please provide any vaccination records you have, including vaccinations given overseas. For children, a copy of the relevant pages from the red book can help. Do not delay registration if records are unavailable.

13 Screening and pregnancy where relevant

14 Lifestyle

15 Ethnic background

How would you describe your ethnic background? This helps us understand our patient population and plan care. Answering is optional.

16 Armed forces

If available, please provide a copy of your service medical summary.

17 Other information

18 How we use your information

We use your personal and health information to register you, provide care and manage health services. Information may be shared with other organisations involved in your care, or where permitted or required by law. Read our privacy notice, which explains how we use and protect your information and your rights.

19 Summary Care Record

A Summary Care Record allows authorised health and care professionals involved in your care to see important information from your GP record, including medicines, allergies and adverse reactions. Additional information can include relevant medical history and communication needs.

Current NHS arrangements include additional information by default where you have not recorded a different preference. Existing choices to limit or opt out of a Summary Care Record continue to be respected.

You can choose a record with additional information, a record containing core information only, or no Summary Care Record. Ask us for information or the NHS patient preference form if you want to review or change your choice.

Leaving this box blank is not a request to change an existing preference.

20 Someone helping with your care

You can ask us to arrange permission for a trusted person to discuss your care or access agreed online services. We will discuss what they can access and complete the relevant checks separately. This registration form does not grant access to your records.

21 Declaration

The information I have provided is accurate and complete to the best of my knowledge. I will tell the practice if my contact details or other relevant information changes.