Stethoscope

Old Road | Tean | Stoke-on-Trent | ST10 4AG | telephone: 01538 722 323

Blythe Bridge Primary Health Care

Tean Surgery

 

 

 

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New Patient Questionnaire

MaleFemale





AfricanAsianAsian BritishBlackBlack BritishCaribbeanChineseMixedWhite

SingleMarriedWidowedDivorcedLiving with partner

YesNone

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YesNoNever

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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:

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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?


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YesNo