Please state any Sensory Impairment you have (i.e. Speech, Hearing, Sight): Are you an Dog’ ‘Assistance User? Please state any Physical disabilities you have: Please state any Mental disabilities you have: Please state any requirements you have to be able to access the Practice premises Please state any Religious or Cultural needs: Please state any specific nutritional requirements you have: Please state any allergies and sensitivities you have: Please state any phobias you have: Person Cared For Contact Details: If you are a Carer, please state the name / address / phone number of the person you care for: Carer Contact Details: If you have a Carer, please state their name / address / phone number and sign here if you wish us to disclose information about your health to your Carer. Signed: Date: Do you have a Will” Yes / No “Living If “Yes”, (a statement explaining what can you please bring a written copy of it medical treatment you would to your New Patient Consultation not want in the future)? Yes / No If please state their name / address / phone “Yes”, number: Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)? Women only: Date: Yes No When was your last Was this at your smear done? GP’s Surgery?
Please state any Sensory Impairment you have (i.e. Speech, Hearing, Sight): Are you an ‘Assistance Dog’ User? Please state any Physical disabilities you have: Please state any Mental disabilities you have: Please state any requirements you have to be able to access the Practice premises Please state any Religious or Cultural needs: Please state any specific nutritional requirements you have: Please state any allergies and sensitivities you have: Please state any phobias you have: If you are a Carer, please state the name / address / phone number of the person you care for: Person Cared For Contact Details: If you have a Carer, please state their name / address / phone number and sign here if you wish us to disclose information about your health to your Carer. Carer Contact Details: Signed: Date: Do you have a “Living Will” (a statement explaining what medical treatment you would not want in the future)? Yes / No If “Yes”, can you please bring a written copy of it to your New Patient Consultation Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)? Yes / No If “Yes”, please state their name / address / phone number: Women only: When was your last smear done? Date: Was this at your GP’s Surgery? Yes No
New%20patient%20registration%20questionnaire%20with%20Audit%20C%20(2).docx