New Patient Registration/Health Questionnaire

All information supplied will be recorded in your confidential medical records.

Online Services

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Contact Details

Gender

Marital status

Ethnicity

Home phone number

Work phone number

Mobile number (if aged 16 or over)

Language preference

English
Welsh
Other

If Other, please specify

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccinations reminders and anything else relevant to your healthcare?

Yes

We have an electronic method of contact available for patients to contact the surgery for non urgent requests - do you consent for us to correspond with you via this method and supply us with a preferred email address for this purpose?

Yes

Email address

Smoking

Do you smoke?

Yes
No
Ex-smoker

If Yes, how many cigarettes per day? ...or ounces of tobacco per day?

If ex-smoker, what date did you stop smoking?

Alcohol

For the following questions please answer to the best of your knowledge.

We have provided a basic guide to alcohol content below to assist your completion.

A 750ml bottle of wine contains 10 units.

A standard(175ml) glass of wine contains 2 units.

A single small shot of spirits (25ml) contains 1 unit.

A standard 70cl bottle of spirits contains 28 units.

A pint of 3.6% strength lager/beer/cider contains 2 units.

A pint of 5.2% strength lager/beer/cider contains 3 units.

How many units of alcohol do you drink a week?

Height & Weight - Please tell us your most recent measurements for the following (if known).

Height

Weight

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

Next of Kin

Name

Relation

Contact number

Family History

The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?

Heart Disease?

Yes

Stroke?

Yes

Cancer?

Yes

Medication

Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.

Name of drug - Dosage

Please add a photo of your most recent repeat medication slip if you have one.

Allergies

Do you have any allergies?

Yes

If Yes, please give details

Past Medical History

Please give details of any treatments/medical conditions.

Carer Information

Do you need / have anyone who looks after you or your daily needs as a Carer?

Yes

If Yes, would you like them to deal with your health affairs here?

Yes

Do you care for anyone else?

Yes

History

Have you been registered here previously?

Yes

Have you moved to the UK from abroad?

Special Circumstances

Military Veteran

Have you ever served in the Armed Forces?

Yes

Communication

Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?

ACCEPTABLE BEHAVIOUR CONTRACT

We are committed to promoting access to our services and offering choice wherever possible in the services we provide and the way we deliver them. An acceptable behaviour contract is an individual written agreement between a patient and their GP practice.

The contract is between:

Your Name

Date of Birth

and Bridgend Group Practice and is valid from the date shown in the signature table below.

Bridgend Group Practice will ensure you are dealt with quickly, fairly and in a courteous and helpful manner. Bridgend Group Practice will ensure that staff take responsibility for resolving or dealing with your query or that they refer it to an appropriate colleague.

The Conditions:

The above-named person applying for registration at the practice agrees to the following:

1. To refrain from using abusive or offensive language, making threats of violence or aggressive behaviour and to treat all staff fairly and with respect; in person, on the phone, in writing or on social media.

2. To cancel any appointments they are unable to attend with as much notice as possible.

3. To Bridgend Group Practice’s DNA (Did Not Attend) policy - if they miss three appointments without notifying the surgery, they may be removed from the practice list and will have to register with a different practice.

4. To adhere to Bridgend Group Practice’s repeat prescription policy and agree to allow two working days before collecting repeat prescriptions.

Breach of this Contract:

If the above-named person fails to adhere to the above conditions, they may be removed from the practice list. This contract serves as an initial warning in the event of breaches occurring.

Declaration:

I confirm that I understand the meaning of this contract and that the consequences of breaking the conditions of the contract.

Yes

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Your signature