New Patient Questionnaire

Please complete this online questionnaire to provide the practice with information about yourself.

Last Updated: 25/05/2023

Your Contact Details

Title *

First Name(s) *

Surname *

Previous Surname

Gender *

Female

Male

Other

Date of Birth *

Town and County of Birth *

Address *

Postcode *

Home Telephone Number

Mobile Number *

Email Address *

I consent to the Practice communicating via SMS Text Messaging and Email *

Yes

Next of Kin Full Name (IN CASE OF EMERGENCIES) *

Next of Kin Telephone Number *

Is Your Next of Kin A Patient At This Practice? *

Yes No

Information About You

Previous GP

Name and Address of Previous GP *

Medical Information

Choice of pharmacy

Which is your preferred pharmacy? *

Lloyds (Cowbridge)

Sylvia Williams (Cowbridge)

Boots (Llantwit Major)

Well (Llantwit Major)

St Athan

Anne Williams (Pontyclun)

Pontyclun

Other

Carers

Do you have a carer? *

Yes No

If yes please provide the name, address of the person who cares for you, their relationship to you and the care given

Are you a carer? *

Yes No

If yes, please provide the name, address of the person, their relationship to you and the care given

Would you like to speak to the practice’s Carers’ Champion?

Yes No

Would you like us to forward your details to the Vale of Glamorgan Carers Development Officer to add your name to the council carers’ database. You will receive publications such as Caring Times and details of courses that are available in the area

Yes No

Smoking

Alcohol

How much alcohol do you drink? *

Teetotal

1-10 units per week

11-20 units per week

21-30 units per week

+30 units per week

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Signature and consent

I declare to the best of my belief this information is correct. By electronically signing below I am consenting to: the choices made in the NHS organ donor register section; the NHS blood donor register if you have selected that preference; and to the Family Doctor Services Registration Form (GMS1) being completed and signed on my behalf by the surgery.

Signature *

Date *

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New Patient Questionnaire

Further Information