GMS1 & New Patient Questionnaire

Fields marked "REQUIRED" are compulsory.

You should only send this form if you are sure that you are eligible to join this practice.

Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 27/03/2023

Patients Details

Title

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Sex

Male (including trans men)

Female (including trans women)

Non-Binary

Address *

Postcode *

Telephone *

Email address

Next of Kin Name

Next of Kin Relationship to Patient

Next of Kin Contact number

Please help us trace your previous medical records by providing the following

Your previous address in UK *

Name of previous GP while at previous address *

Address of that Doctor *

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

New Patient Information

What is your ethnicity? *

Height (cm)

Weight (kg)

Do you smoke? *

How often do you have a drink that contains alcohol?

How many standard alcoholic drinks do you have on a typical day when you are drinking?

How often do you have 6 or more standard drinks on one occasion?

Are you the main carer for someone? *

Yes No

Do you have a carer? *

Yes No

Do you take any regular medication? *

Yes No

What is your main language?

Do you require an interpreter? (BSL or Translator)

Yes No

What is your religion?

Nominated Pharmacy

Which chemist would you like to use as your nominated pharmacy? *

If you are completing this form for a person under 18

Does the child or anyone living in the household have a social worker?

Yes No

Is the child subject to a child protection plan?

Yes No

Do you have parental responsibility for the child?

Yes No

Complete Registration

Name of person completing this form *

Signature *

Signature of patient

Signature on behalf of patient

Date *

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GMS1 & New Patient Questionnaire

Further Information