TOOTING SOUTH MEDICAL CENTRE 
NEW PATIENT QUESTIONAIRE

Please fill out this form in capital letters

Date of registration…………………………………………………………………….…………………………….

Surname………………………………..…First name(s)………….............................................................

Full address………………………………………………………………………………………………..…………

…………………………………………Post code…………………………..………………………………..…….

Telephone number…………………….…..…Mobile……………………………………...………………..……

Do you identify as trans?  Yes / No / Unsure
(this means your gender is different to the one assigned to you at birth.)

Date of birth……………………….                         Gender: Male / Female / Non-Binary

First Language: ……………………..……….                 Do you need an interpreter? Y/ N
                                                                                                     
Marital status: Single / Married / Divorced / Cohabiting.

Occupation………………………………………..Country of origin………………………………………..……..

PLEASE CIRCLE YOUR ETHNICITY

British or mixed British, Irish, Other White background,  White and Black Caribbean, White and Black African, White and Asian, other Mixed background,  Indian or British Indian, Pakistani or British Pakistani, Bangladeshi or British Bangladeshi, Other Asian background, Caribbean, African, Other Black background, Chinese,  other………………………………………………………………………………….……
Prefer not to say

PLEASE CIRCLE YOUR SEXUAL ORIENTATION

Heterosexual (straight), Homosexual (gay/lesbian), Bisexual, Other…………………….……….
Prefer not to say

RELIGION………………………………………………………………………………………………..…………

NEXT OF KIN

Next of kin or emergency contact details:     Title: Mr/Mrs/Ms/Dr

First name…………………………………………...…Surname……………….…………………………..…

Relationship to a patient……………..……..........Telephone number………………..…..…………...……

CARERS

Are you a carer? Yes/No
Do you have a carer?           Yes/No
If “Yes”, then please provide us your carer details:  

Full name…………………………………………………………………………………………………………….

Contact details………………………………………………………………………………………………………

GENERAL HISTORY

Have you had any serious illnesses or operation, x-ray or similar tests and when?  
……………………………………………………………………………...………………………………..………

Do you suffer from Asthma, Diabetes, Hypertension, Heart Condition any Neurological?
Condition, Mental health, Depression?

..................................................................................................................................................................

Do you have HIV, Hep B or Hep C ?

..................................................................................................................................................................

Are you taking any medications? 
.................................................................................................................................................................

Are you allergic to any medicine or anything else? .................................................................................................................................................................

How much tobacco or cigarettes do you smoke a day? ..........................................................................

How much alcohol do you consume?  …………………………….............................................................

FAMILY HISTORY

Is there any of the following in your family (father, mother, brother, sister) before age of 65?

Heart attack Y/N   Asthma Y/N   High blood pressure Y/N   Diabetes Y/N   Stroke Y/N   Tuberculosis Y/N   Chronic bronchitis Y/N Cancer Y/N Epilepsy  Y/N Mental health/Depression Y/N.
Any other serious illnesses Y/N 

VACCINATIONS

Which vaccination have you had and when?

Diphtheria Y/N   Polio Y/N   Tetanus Y/N   German measles Y/N   Typhoid Y/N   Measles Y/N   Cholera Y/N BCG Y/N   Yellow Fever Y/N   MMR Y/N   Whooping cough Y/N   Other Y/N

IF YOU NEED A CHAPERONE WHEN YOU SEE THE DOCTOR/NURSE/HEALTH CARE ASSISTANT PLEASE SPEAK TO RECEPTION STAFF.

TEXT MESSAGES
Do you give us consent to contact you via text messages      Yes   /   No       

FOR PATIENTS WITH A CERVIX ONLY

When was your last smear test done?.....................................................................................................

SUMMARY CARE RECORD
Summary care record is an electronic record that will give healthcare staff faster and
easier access to essential information about you, to help provide you with a safe treatment when you need
care in an emergency or when you’re GP is closed. Summary care record includes access to your
medication, allergies and adverse reactions.
If you do not want a summary care record you need to let your GP Practice know by filling in 
and returning an OPT-OUT form. Please see reception for this.

ONLINE SERVICE
The Practice currently offers GP routine appointments to registered patients over the age of 18. We offer patients to view and request medications online. To get patient access account please contact the reception. You need to bring your photo ID and fill in patient online registration form.

ACCESSABLE INFORMATION STANDARD

Do you need information in a different format? Do you need support?
Tell us today by ticking the box below:

Accessible Information Standard 
(for patients with a disability, impairment or sensory loss)

My information and communication preferences are:
  Easy Read     	       Large Print     	      BSL     				  
          Email      		                  Text      	    Other  __________

Practice registration form – last update June 2018

ALCOHOL – AUDIT C

Questions	Scoring system	Your 
score	
	0	1	2	3	4		
How often do you have a drink containing
alcohol?	
Never	
Monthly
or less	2 – 4
Times
Per
month	2 – 3
Times
Per
month	4+
Times
Per
month		
How many units of alcohol do you drink on a typical day when you are drinking?	1 - 2	3 - 4	 5 - 6	7 - 9	10 +		
How often have you had 6 or more units if female, or 8 or more if male, on a single
occasion in the last year?	
Never	Less
Then
monthly	
Monthly	
Weekly	Daily
or
Almost
daily		

Scoring

A total of 5+ indicates increasing or higher risk drinking.                                      SCORE
An overall total score if 5 or above is AUDIT-C positive                                    

Score from AUDIT – C (other side)

                                                                                                                                         SCORE                                  

Remaining AUDIT questions

Questions	Scoring system	Your score	
	0	1	2	3	4		
How often during the last year have you found that you were not able to found that you were not able to stop drinking once you had started?	 

Never
	
Less 
than
monthly	

Monthly	

Weekly	Daily 
or almost daily 		
How often during the last year have you failed to do what was normally expected from you because of drinking?	

Never	
Less than
monthly	

Monthly	

Weekly	Daily 
or almost daily 		
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drink session?	

Never	
Less than
monthly	

Monthly	

Weekly	Daily 
or almost daily 		
How often during the last year have you had a feeling of guilt or remorse after drinking?	
Never	
Less than
monthly	
Monthly	
Weekly	Daily 
or almost daily 		
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	

Never	
Less than
monthly	

Monthly	

Weekly	Daily 
or almost daily 		
Have you or somebody else been injured as a result of your drinking?	
No		Yes, but not in the last year 		Daily 
or almost daily 		
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?	
No		Yes, but not in the last year 		Daily 
or almost daily 		

Scoring: 0 – Lower risk, 8 – 15 increasing risk, 
16 – 19 Higher risk, 20+ Possible dependence                                                                                                                                                                    

	
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