New Patient Questionnaire

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Background Details
Country of Birth
Ethnicity
Language
Communication Needs
Carer Details
*Please add in the name of your carer, telephone number and relationship to you but only if they have given their consent to have their details on your medical record.
Military Veteran, Military Personnel and Service Families
 
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Medical History
Family History
Allergies
 
Current Medication
 
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Alcohol - AUDIT-C (A score of less than 5 indicates lower risk drinking)
Scores of 5 or more require the below questions (AUDIT) to also be completed.
 

This form collects personal and medical information about you. We use this information to confirm you are registered with the practice and to allow the practice team to contact you if applicable. The information you send helps us to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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