Wooler Health New Patient Questionnaire

Please complete all parts as it may be a while before we get your records from your old GP.

Last Updated: 21/11/2023

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Information About You

Previous GP

Name and Address of Previous GP *

Proof of Identity and Address Provided

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitor's Letter

Offer of Tenancy

Other

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details of who you care for

Women

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result

Will

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

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? *

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

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)

Contacting You

Signature

Signature *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Wooler Health website

Wooler Health New Patient Questionnaire

Further Information

Connect With Us