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.

Last Updated: 26/04/2022

Patient Details














Are you a Carer?






Your Health

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











Women




Family Medical History




Ethnicity



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.










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