Adult Questionnaire New Patient Registration Questionnaire(Adult: 16 Years old and over) Patient Details* MrMrsMissMsOther Name* First NameLast Name Previous Surnames/Maiden Name Date of birth* -Day -MonthYearDate NHS No (if known) Gender* MaleFemaleOther Home Address* Street Address Street Address Line 2 CityCounty Post Code Mobile Phone Number* Home Phone Number* Email Address* example@example.com Are you currently employed* Full-TimePart-TimeSelf-EmployedUnemployed Which best describes you* RetiredStudentHousewife/Househusband/homemaker/other Your first choice of contact* LetterEmailTextPhone Ethnicity* White EnglishWhite Northern IrishWhite ScottishWhite WelchWhite CypriotWhite GreekWhite Greek CypriotWhite TurkishWhite Turkish CypriotWhite ItalianWhite PolishWhite KosovanWhite and Black CaribbeanWhite and Black AfricanWhite and AsianBangladeshi/British BangladeshiBritish AsianIndian/British IndianBlack BritishBlack CaribbeanBlack AfricanBlack NigerianBlack SomaliChineseJewishIranianArabLatin AmericanNorth AfricaOtherI do not wish to disclose What is your second language? (If applicable) Do you need an Interpreter?* YesNo Please choose your religion* Church of EnglandCatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah's WitnessNo ReligionPrefer not to say NHS Regulations 2015 Self-Declaration* I am a British resident and entitled to full NHS careI hold a non-UK issued European Health Insurance Card (EHIC)I hold an S1 form (entitled to health care in another European Economic Area country for a limited duration) Next of Kin Next of kin full name* First NameLast Name Relationship to Patient* Contact Phone Number* Carers Are you a carer for someone who is ill, frail, disabled, has substance problems or has mental health needs?* YesNo Do you have a carer?* YesNo Are you housebound* YesNo Do you need help with mobility/hearing/speaking?* YesNo Medical Records Please help us trace your previous medical records by providing as much of the following information as possible: Your previous address in the UK Street Address Street Address Line 2 CityCounty Postcode Name of previous Doctor while at the address Address of previous doctors Street Address Street Address Line 2 CityCounty Postcode If you are returning from armed forces Address before enlisting Street Address Street Address Line 2 CityCounty Postcode Service or personnel number* Enlistment Date -Day -MonthYearDate Submit Should be Empty: