NHS

12 High Street, Fochabers, IV32 7EP

Telephone: 01343 820247

Fax: 01343 829930

fochabersadministrator@nhs.net

It's Thursday 10:39 PMSorry, we're closed

New Patient supplementary questionnaire – Under 16s

New Patient Supplementary Questionnaire Under 16s

Please be advised that it can take a considerable time for your medical records to reach us. The information required in this form is required in order to help us better facilitate your immediate needs and will be treated with the strictest confidence. This form can be completed at the practice; or be downloaded and e-mailed to the practice at aberlour.administrator@nhs.net but it must be signed at the medical practice and witnessed by a staff member. The form is to be completed by the requesting patient in conjunction with NHSG Form GMSGPR001
  • Date Format: DD slash MM slash YYYY
  • Please detail as much of your medical history that you feel will help us better facilitate your immediate medical needs. Include: previous serious illnesses and dates of significant operations
  • Please detail any current medication that you are currently prescribed including: name, dosage, and how often taken
  • Please list any drug allergies that you have
  • Please let us know of anyone in your family for whom has a history of: Heart disease, Stroke, Cancer, or diabetes
  • How many cigarettes do you smoke in a day? If you are an ex smoker how many cigarettes did you smoke in a day?
  • Please select all immunisations that you are aware you have had
  • Please let us know of any additional immunisations that you are aware of having
  • Any other information that will help to better inform the GP of your medical needs?
  • GP's name and the name and address of your previous GP medical practice
  • We will have to contact your previous medical practice in order to have an up-to-date record of your current medical needs. Please indicate your consent for us to do this