New Patient Health Questionnaire Title Mr Mrs Ms Miss Mx Other Name First Name Surname Date of Birth Day Month Year Current Address Street Address Address Line 2 City Postcode Occupation Optional Contact InformationEmail Address Optional Contact Number OptionalAre there any other methods by which we can contact you? OptionalNext of Kin / Emergency ContactName First Name Surname Relationship to you Contact NumberCurrent Address Street Address Address Line 2 City Postcode IdentityGender Woman (Including Trans Woman) Man (Including Trans Man) Non-binary Other Is your gender identity the same as the gender you were assigned at birth? Yes No Preferred Pronouns She/Her/Hers He/Him/His They/Them/Theirs Other Sexual Orientation Optional Are you in a relationship? Yes Optional No Optional Ethnicity Optional Medical InformationHeight Optional Please specify the unit of measurement for Height and Weight Weight Optional Blood Pressure Optional If you are unable to provide these measurements from home please contact the surgery to book an appointment with the nurse. Name of Previous GP (If none, please enter “NA”) Do you have any children? Yes No How many children do you have? Optional Please provide their names and dates of birth OptionalPlease fill out JUST the registration form for any child 12 and under, children 13+ need to fill out the registration form and health questionnaire.Do you have any pre-existing medical problems? Yes No Please Specify Do you have any allergies? Yes No Please Specify Are you taking any medication? Yes No Please Specify Which pharmacy would you like your medication to be sent to? Optional (If you are unsure, we suggest selecting the Manor Pharmacy located in the building next to the practice. To find a local pharmacy, click here.)In the last 3 months, have you been drinking alcoholic drinks? Yes No On average, how many units per week do you consume? Optional In the last 3 months, have you been smoking cigarettes? Yes No On average, how many cigarettes do you smoke per day? Optional Would you like to discuss quitting/reducing your smoking with a clinician? Yes No Are you a carer? Yes No Have you ever served in the armed forces? Yes No If you would NOT like your details to be uploaded to the Summary Care Records, please contact reception for our OPT-OUT form to be filled in and handed to reception.Benzodiazepine and Analgesic PrescribingThis surgery does not issue on going Benzodiazepine (e.g. Diazepam, Zopiclone and Temazepam) prescriptions to newly registered patients. Patients taking this kind of medication will be offered a reduction programme, which will last 8 weeks. Patients taking regular Analgesic Medication (e.g. Tramadol, Codeine, Morphine and Dihydrocodeine) will be asked to attend surgery for a medication review with the GP. Agreement to this policy is a strict requirement for registration with this practice. Patients unwilling to comply with this policy are advised to consider registering with another practice. Yours Sincerely DR S Mohankumar & PartnersPatient AgreementI agree to comply with The Chandler Surgery’s Benzodiazepine and Analgesic Policy.Patient Date of Birth Day Month Year Patient Signature (Your Full Name)
