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

 

 

 

featured_image

 

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

Skip to content