Village Health Group - New Patient Questionnaire Form

This form should be used in conjunction with the Village Health Group Permanent Registration form. If we only receive one of the two forms (for patients aged 5yrs and above), please be advised we may contact you to complete the outstanding form before we are able to register you with the surgery.

Last Updated: 22/12/2020

Your Contact Details











Information About You






Previous GP


Medical Information













Carers

A carer is anyone, including children and adults who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid.





Women



Will



Smoking





Alcohol




Family History


Next of Kin




For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)



Contacting You


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