LS New Patient Questionnaire

LS New Patient Questionnaire

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

  • Patient Details

    Have you previously been registered at Lodge Surgery?
    Date of Birth
    For example, 15 3 1984
    PLEASE CONFIRM CONSENT TO CONTACT YOU BY SMS
    PLEASE CONFIRM CONSENT TO CONTACT YOU BY EMAIL

  • Are you a Carer?

    Do you provide care for someone?
    Does someone provide care for you?
    Would you like to register as a Carer with us?
    Do you have communication needs relating to a disability, impairment or sensory loss?

  • Your Health

    If you need repeat medication within the next 4 weeks please submit hte form and then contact the surgery.

    Have you ever smoked?
    Do you need repeat medication within the next 4 weeks?
    Have you ever considered stopping? If so, please make an appointment with our Smoking Cessation Advisor for a chat. (optional)
    Do you have any allergies?

  • Women

  • Family Medical History

    Family History (optional)

  • Ethnicity

    Please tick the boxes that apply: (optional)

  • Online Services Account

    On registration we will arrange for you to have access to online appointment booking, repeat prescription requests and enable you to view your records online from the date of registration.

  • Record Sharing

    Lodge Surgery would like to share your medical records with our local surgeries as part of our Primary Care Network so that we can provide patients with additional services. If you do not wish your records to be shared please inform the surgery.

  • NEW PATIENT CHECK

    If you would like to have a new patient health check up please make an appointment to see the Health Care Assistant.

  • Your alcohol consumption

    This questionnaire is taken from the WHO AUDIT questionnaire: screen for alcohol misuse. For each question select your answer and note the score in brackets. Upon completion of the questionnaire add up your total score and compare it to the profile given at the bottom of the page. One unit of alcohol is 1/2 pint average strength beer/lager OR one small glass of wine OR one single measure of spirit. Note: a can of high strength may contain 3-4 units.

    How often do you have a drink containing alcohol?
    How many units of alcohol do you have on a typical day when you are drinking? (optional)
    How often do you have 6 or more units on one occasion?
    During the past year, how often have you found that you were not able to stop drinking once you had started?
    During the past year, how often have you failed to do what was normally expected of you because of drinking?
    During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
    During the past year, how often have you had a feeling of guilt or remorse after drinking?
    Have you or someone else been injured as a result of your drinking?
    Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

  • Please submit your form

    I understand that in order for my registration application to be processed I must also complete the New Patient Registration Form (GMS1) and the Summary Care Record.
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Page last reviewed: 26 April 2022
Page created: 26 February 2021