Stethoscope

Old Road | Tean | Stoke-on-Trent | ST10 4EG | telephone: 01538 722 323
For the Dispensary telephone: 01538 722 215

Blythe Bridge Primary Health Care

Tean Surgery

 

 

 

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New Patient Questionnaire

    MaleFemale





    AfricanAsianAsian BritishBlackBlack BritishCaribbeanChineseMixedWhite

    SingleMarriedWidowedDivorcedLiving with partner

    YesNone

    YesNo

    YesNo

    YesNo

    YesNoNever

    YesNo

    YesNoNever

    YesNo

    OnceTwiceThree timesFour or more

    Due to the new registration process each new patient over the age of 14 must have a blood pressure/urine check. This can be done simply and only takes a few minutes with our Health Care Support Worker but if you suffer from any of the following you will need a slightly longer check-up with the Practice Nurse. Please select all of the following which apply to you:

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    If you are on regular medication please bring your prescription request slip with you including any not prescribed by you previous doctor.

    YesNo

    Is there a history in your immediate family (parents, brother or sister) of any of the following?


    YesNo
    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

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