Stoke Gifford Medical Centre

0117 9799430

New patient health questionnaire

Please complete both this form and the patient registration form to allow us to process your registration.

  • Your Contact Details

  • Date Format: DD slash MM slash YYYY
  • Information About You

  • Previous GP

  • Proof of Identity and Address Provided

  • Medical Information

  • Have you ever suffered from? (tick as appropriate)
  • Medical Information (continued)

  • Have you ever suffered from? (tick as appropriate)
  • Carers

  • Will

    (A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
  • Women

  • Smoking

  • Alcohol

  • 1 drink = 1/2 pint of beer OR 1 glass of wine OR 1 single spirit
  • Family History

  • Next of Kin

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

  • Contacting You

  • Signature

  • Date and signature

    (you will be asked to sign this form when you visit the practice)