Personal Details Date of Birth Address
Email
Demographics
Please help us trace your previous medical records by providing the following information: Your previous address in the UK
Address of previous doctor
Are you from abroad?
If you are from abroad Your first UK address where registered with a GP
If previously resident in UK, date of leaving Date you first came to live in the UK Are you ordinarily a resident in the UK? What is your current immigration status?
European Economic Area (EEA) Country Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Communication Needs
Disability
Armed Forces Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Do you have access to secure housing?
Carers
Emergency Contact
About You Are you interested in advice on how to quit? Please state how much exercise and what type of exercise you do per week Optional
Alcohol Consumption Family history : Optional
Major Illnesses Optional
Please include dates Past operations/surgeries Optional
Please include dates Current Medication Optional
Allergies Please specify what you are allergic to, what happens and when you had your first reaction
Immunisation History Please provide a list of any immunizations or vaccinations you have received (include dates). Optional
Important Registration Information
Summary Care Record Do you consent to having a Summary Care Record?
Your Medical Information – Sharing Your Data
NHS Organ Donor registration
NHS Blood Donor registration
What happens to my information?
Signature Declaration Date