Patient Questionnaire for Adults

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this Practice and that you live within our Practice boundary. Sending this form does NOT guarantee or imply that you will be accepted onto the Practice register. Please allow up to five working days for us to process your registration.

Last Updated: 15/05/2022

Your Contact Details

Next of Kin

(or who to contact in an emergency)

Contacting You

To preserve resources and to be environmentally friendly, we will contact you by SMS or email, unless you specifically state 'No' in which case we will write to you

Communication Needs

The Accessible Information Standard aims to ensure patients and/or their carers who have a disability or sensory loss can receive, access and understand information in a suitable format e.g. large print, braille, email or from a British Sign Language interpreter. Individuals most likely to be affected by the Standard are those who have sight and/or hearing loss and people with a learning disability (this list is not exhaustive)

Information About You

Collecting this information helps result in better health outcomes and helps prevent health care inequalities.,

Medical Information

Family History





Sharing Your Health Record

With the development of information technology, the NHS will increasingly be sharing key information from your GP Medical Record with Out of Hours GP Services, Hospital A&E Units, Community Hospitals, Community Nurses, all of who may be looking after you at various points in your life. Sharing your information can improve the quality and safety of care you receive and in some cases can be vital in making life-saving decisions about your treatment.

NHS Summary Care Record (SCR)

The SCR was introduced many years ago to help deliver better and safer healthcare. It contains basic information about and allergies you may have, unexpected reactions to medications and any prescriptions you have recently received. The intention is to allow Hospital A&E departments and Out of Hours health services to give you safe, timely and effective treatment. Over time, health professionals treating you may add details about your health to the SCR with your consent.


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