Medlock Vale Medical Practice

58 Ashton Road, Droylsden, Manchester, M43 7BW

Telephone: 0161 370 1610

GMICB-tameside.medlockvalemedicalpractice@nhs.net

We're open

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Patient Participation Group GP Average Earnings

New Patient Questionnaire

For us to ensure a smooth process of registration, please ensure ALL questions are answered. Please note - if the questions are not answered correctly, this will delay your registration.

Patient Details

Title:(Required)

Other (Please state)

Full Name(Required)

First Middle Last

Date of Birth(Required)

Gender(Required)

Other (Please state)

Occupation

Marital Status

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Mobile Number

Home Telephone Number

This field is hidden when viewing the form

Section Break

Ethnic Origin(Required)

Other (Please state)

Untitled

Next of Kin Details

Name(Required)

First Last

Relationship(Required)

Mobile Number(Required)

Home Telephone Number

Language Support

What is your first language?(Required)

Do you speak English?(Required)

Yes

Do you require an interpreter?(Required)

Yes

Do you use any of the following?(Required)

If yes, which language?

Additional Information

Religion(Required)

Other (Please state)

Are you a Military Veteran?(Required)

Yes

If yes, do you give permission for this to be recorded in your medical notes?

Yes

Are you a carer?(Required)

Yes

If yes, who do you care for:

Health Overview

Height (cm)(Required)

Weight (kg)(Required)

BMI

Blood Pressure

Pulse Rate

Smoking Status:

Smoking Status(Required)

Never Smoked

Ex-Smoker

Current Smoker

How many per day?(Required)

Alcohol Status

Approximate number of alcohol units consumed per week:(Required)

How often do you have an alcoholic drink?(Required)

Never

Less than monthly

Monthly

Weekly

More than 4 times per week

How many units of alcohol do you have on a typical day when you are drinking?

1-2

3-4

5-6

6 or more

How often do you have 6 or more (female) or 8 or more (male) units on one occasion?(Required)

Never

Less than monthly

Monthly

Weekly

Daily / almost daily

Personal and Family History

Have you or a close relative ever had any of the following illnesses? * Please state the nature of relationship

Asthma

Yourself	Relative

*Nature of Relationship

High BP

Yourself	Relative

*Nature of Relationship

Glaucoma

Yourself	Relative

*Nature of Relationship

Cancer

Yourself	Relative

*Nature of Relationship

Diabetes

Yourself	Relative

*Nature of Relationship

Stroke

Yourself	Relative

*Nature of Relationship

High Cholesterol

Yourself	Relative

*Nature of Relationship

Depression

Yourself	Relative

*Nature of Relationship

Other (Please state)

Do you consider yourself to have any disabilities? If yes, please state

Do you have any allergies? If yes, please state

Summary Care Record

A Summary Care Record (SCR) is an electronic record of important patient information created from GP medical records. They can be seen and used by authorized staff in other areas of the health and care system involved in your care. You may also wish to get further information from this website: https://digital.nhs.uk/services/summary-carerecords-scr ...... If you DO NOT want a Summary Care Record, please complete the following section:

No – I do not wish to have a Summary Care Record (please tick) – I understand that this means, should an emergency arise, healthcare staff will be unable to access information regarding any medication I am taking, any allergies I suffer from or any bad reactions to medicines I have. I understand that I can opt back in at any time by contacting my GP practice.

Communication

Text Messaging: If you have a mobile phone number you can receive messages regarding appointments confirmations, appointment reminders, health campaigns (eg. flu jab). Please tick the following if you wish to OPT OUT to this service:

Yes – I do not want Medlock Vale Medical Practice to send text messages to my mobile phone number

EPS Nominated Pharmacy

Please state the name of your nominated pharmacy:

Confirmation

I confirm that I have read and understood all of the above information and give or do not give my consent as indicated in each section.

Name

First Last

Signature

Date

Please note - you will be asked to bring your Photo ID and proof of address down to the surgery before we can complete your registration, or alternatively you can upload a copy below.

Please upload your photo ID here -

Max. file size: 128 MB.

Opening Times

Monday
07:30am to 06:30pm
Tuesday
07:30am to 06:30pm
Wednesday
07:30am to 06:30pm
Thursday
07:30am to 06:30pm
Friday
07:30am to 06:30pm
Saturday
CLOSED
Sunday
CLOSED

Useful Links

	Very easy	Fairly easy	Not very easy	Very difficult	N/A
Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

Medlock Vale Medical Practice

New Patient Questionnaire