New Patient Medical Questionnaire

Please complete this form and come to the practice to complete your GMS1 form and provide the required identification documents. It can take approximately six weeks before we receive your medical records from your previous surgery. By completing the below we will have a good knowledge of your medical history should you wish to see a GP/nurse. All information given will be treated in the strictest of confidence.

Information About You And Your Health

Full Name - Including Title

Previous Name

Address With Postcode

Mobile Number

Landline Number

Date Of Birth

Any Allergies?

Any Relevant Medical History?

Are You Taking Any Regular Medication?

Information About Your Lifestyle

Do you smoke?

If Yes, how many per day?

Would you like any help in giving up smoking?

Do you drink alcohol?

If so, how often and what do you drink?

Do you do any physical activity (walking/aerobics/working/housework etc)?

How many times per week?

Family Health

If yes to any of the previous family history, please state which condition/s and which relative/s:

If you have Cancer what type Is it?

Questions

Do you have a carer ?

Do you give us consent to discuss your Health Problems with them?

Accessible Information Standard

In accordance with The Accessible Information Standard please accept the below as formal notification of information and communication preferences. This includes carers. We offer on line ordering of repeat medication also and an easy read leaflet of how it works available at reception.

I communicate using :(e.g. BSL, deafblind manual, text)

To help me communicate I use:(e.g. a talking mat, hearing loop & hearing aids)

I need information in: (e.g. braille, easy read)

If you need to contact me the best way is:(e.g. email, telephone)

SMS (Text) Messaging Service

We may use SMS messaging to communicate with patients who have provided us with a mobile number, for the purposes of health education/promotion, data collection, test results and appointment reminders.

Please let us know if you wish to opt out of this

We do not currently offer a reply facility unless requested by us in the message.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Stopgate Lane Medical Centre • 6 Stopgate Lane, Liverpool, L9 6AP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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