Additional Registration Questions

Please complete this to give us more information about your health and things that can impact on health.

Patient Details

Name

Date of Birth
Communication

Do you have difficulty understanding information about your health or treatments that you are receiving?

Yes

No

If yes, please give information.
Housing

Do you have any problems with housing?

Yes

No

If yes, please given information.
Money

Do you have any money problems that make it hard to meet your needs?

Yes

No

If yes, please give information.
Social

Do you feel lonely?

Yes

No

If yes, please give information.
Language

What is you main spoken language?

If not English, would you need an interpreter?
Contact

What is your preferred method of contact?

Mobile

Landline

Text

Email

Post
Health Support

Would you like help with stopping smoking, exercise or healthy eating?

Yes

No
If you answered yes to any of the questions:

Do you feel a referral for support would help?

Yes

No
Where did you hear about our surgery?

Please choose from the following options

online/ search engine

NHS website

Friend, family or colleague

Surgery website

Other

Please enter details here

Other - Please state

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