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Ground Floor, Alfred Health Centre
186 Homerton High Street, E9 6AG

Tel: 020 8986 3106   Fax: 020 8985 1909
Out of Hours: (CHUHSE) 0208 185 0545

Online Registration

Please complete the below registration form by filling in as much information as possible. All questions marked * must be completed otherwise your registration cannot be processed.

Please note your registration is not complete until you have a new patient check with the health care assistant. To complete your registration with the surgery you will need to visit the practice with proof of Identification and proof of address.

 

Confidential - Health Questionnaire for New Patients

 Patient Number:
 
 

Personal Details:

 Family Name:
 
 First Name:
 
 Date of Birth:
 
 Telephone Number: Home:
 
 Telephone Number: Work:
 
 Telephone Number: Mobile:
 
 Email Address:
 
 Gender:
 
 Next of Kin (Name):
 
 Contact No:
 
 Personal Status:
 
 

General Needs

 Do you need support with spoken english?
 
 Do you consider yourself to have a disibility?
 
 Do you help and support someone on a regular basis?
 
 Does anyone help and support you on a regular basis?
 
 Interpreter required:
 
 Which language do you require a interpreter for?
 
 Sign Language:
 
 Hearing Aid:
 
 Are you a Carer?
 
 Are you any of the following?
 
 

Ethnic Origin

 Black or Black British
 
 Any other black background:
 
 Mixed
 
 Any other mixed background:
 
 White
 
 Any other White background:
 
 Asian and Asian British
 
 Any other Asian background:
 
 Chinese or other Ethnic groups
 
 Any other ethnic group:
 
 

Present and Past Illnesses

 Have you any current or past medical problems?
 
 If Yes, please give Dates/Details:
 
 Is there a history of alcohol misuse?
 
 Is there a history of drugs misuse?
 
 Do you suffer from any allergies?
 
 If so, please state including medication:
 
 Are you taking any regular medication including the contraceptive pill?
 
 Name and dose of medication:
 
 

Family Medical History

 Heart attack or Angina:
 
 Stroke:
 
 Sugar Diabetes:
 
 Asthma:
 
 High Blood Pressure:
 
 Cancer:
 
 If yes, please state which family member and which type of cancer they had:
 
 Is there any history of domestic violence and/or involvement with social services?
 
 

BMI - Body Mass Index

 Height:
 
 Weight:
 
 Blood Pressure:
 
 

Life Style - We provide a stop smoking clinic for registered patients.

 Do you smoke?
 
 What year did you start smoking?
 
 Are you an ex smoker?
 
 What year did you stop smoking?
 
 Cigerettes?
 
 No. per day?
 
 Cigars/Pipes?
 
 No. per day?
 
 Roll-ups?
 
 No. per day?
 
 

Drinking

 How often do you have a drink that contains alcohol?
 
 Scoring System - Never = 0, Monthly or Less = 1, 2-4 times per month = 2, 2-3 times per week = 3, 4+ times per week = 4
 Your Score
 
 How many standard alcoholic drinks do you have on a typical day?
 
 Scoring System - 1-2 = 0, 3-4 = 1, 5-6 = 2, 7-8 = 3, 10+ = 4
 Your Score
 
 How often do you have 6 or more standard alcoholic drinks on one occasion?
 
 Scoring System - Never = 0, Less than Monthly = 1, Monthly = 2, Weekly = 3, Daily or almost daily = 4
 Your Score
 
 Scoring System - Scoring: A total of 5+ indicates hazardous or harmful drinking
 

Exercise

 Do you take regular exercise?
 
 

HIV Screening

 We provide HIV screening to newly registering patients
 

Women only

 When was your last smear/PAP smear done? (Date):
 
 Have you had a Hysterectomy?
 
 Aged 16-24:
 Are you interested in Chlamydia screening?
 
 Patients Signature
 
 Date