New Patient Health Questionnaire (Adult)

Your Contact Details
Title
First name*
Surname*
Previous Surnames
Occupation
Date of birth*
Day
Month
Year
Home Telephone*
Work Telephone
Mobile Telephone
Home Address (inc. flat number if appropriate)*
Postcode*
Email address*
Enter Email Confirm Email
Information About You
What is your height?*
What is your weight?*
What is your first language?*
Do you need an interpreter?*
- Yes
- No
Ethnicity*
- White British
- White Irish
- Black Carribbean
- Black African
- Asian Indian
- Asian Pakistani
- Asian Chinese
- White + Black Carribbean
- White + Black African
- White + Asian
- Prefer not to say
Which of the following best describes how you think of yourself?
Which of the following best describes how you think of yourself?*
- Woman (including trans woman)
- Man (including trans man)
- Non-binary
Is your gender identity the same as you were given at birth?*
- Yes
- No
Which of the following best describes how you think of yourself?*
- Lesbian
- Gay
- Bisexual
- Heterosexual/Straight
Have you been registered at this practice before?*
- Yes
- No
What is your employment status?*
Please tick all options that apply
- Employed (full time)
- Employed (part time)
- Student (full time)
- Student (part time)
- Unemployed
- Retired

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.
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Have you had a flu vaccination? If yes, please specify the date.
Have you had a pneumococcal vaccination? If yes, please specify the date.
Contacting You
Please consent to being contacted
- I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.
Your Data Matters to the NHS
Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments.
In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used.
You can choose whether your confidential patient information is used for research and planning.
To find out more visit : nhs.uk/your-nhs-data-matters or call 0300 303 5678
You can change your choice at any time.
Online services*
Would you like to register for on line services so you can:
- Book & Cancel Appointments online
- Order Repeat Medication online
- View aspects of your medical record
- None of the above
Signature
Date and signature
(you will be asked to sign this form and/or prove your identity when you visit the practice)
Consent*
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.

Step 1 of 5

Your Contact Details

Information About You

Previous GP

Further information

Proof of Identity and Address Provided

Medical Information

Have you ever suffered from? (tick as appropriate)

Medical Information (continued)

Carers

Electronic Prescription Services (EPS)

Will

Women

Smoking & Lifestyle

Alcohol - How many units of alcohol do you consume in a week?

Scoring

Family History

Next of Kin

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Contacting You

Your Data Matters to the NHS

Signature

Date and signature

Helpful links

Further Info