New Patient Questionnaire

Thankyou for visiting The Wells Clinic today. So that we may provide the best care possible, please take a few minutes to complete our New Patient Questionnaire.

Please note that all information provided is strictly confidential and is held in accordance with the Data Protection Act.

Full Name*

First NameLast Name

Todays Date*

DayMonthYearHourMinutesAM/PM Option

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

Town/CityCounty

PostcodeCountry

Telephone*

Area CodePhone Number

E-mail*

Usual GP/NHS GP name

GP address*

Street Address

Street Address Line 2

Town/CityCounty

PostcodeCountry

Please check this box if you are happy for us to communicate with your usual GP such as writing to let them know you attended our clinic*

I am happy for you to communicate with my usual GP

Tell us how you would like to be contacted*

PostEmailText messageTelephone

Tell us how you would like us to send confidential information such as blood results, xrays results. Please bear in mind the level of security of the options you choose.*

PostEmailText messageTelephone

ALLERGIES*

Medication*

Past medical problems

Please indicate date of diagnosis and any other relevant information to all which apply.

High Blood pressure

Diabetes

Asthma

COPD

Heart attack/angina

Stroke

Epilepsy

Depression

Cancer

Arthritis

Other conditions

Lifestyle

Please answer these questions honestly in order that we can help you in the best way possible.

Do you smoke?

YesNoEx-smoker

If so, how many cigarettes per day?

Do you drink alcohol?

YesNo

How much in an average week?

Please tick this box to indicate you have read our disclaimer below and to indicate that you are happy for us to send confidential information via the above channels as you have chosen above.

Option 1Option 2Option 3

Disclaimer

Sending information via the internet cannot guarantee 100% security. Should you have any concerns about sending your personal details using the web, please attend your appointment 15-20minutes prior to your appointment in order to complete a form by hand.