The Hart Surgery

The Hart Surgery

York Road, Henley-on-Thames, Oxfordshire, RG9 2DR

Current time is 16:52 - We're open

Online New Patient Questionnaire

Thanks for filling out the online GMS1 form to register with The Hart Surgery.

Step 2

You now need to fill out a new patient questionnaire, giving us basic health information as it may be some time before we receive your health records from NHS Central.

Online New Patient Questionnaire

New Patient Questionnaire

"*" indicates required fields

Name
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or any other LGBTQIA2S+ information you would like us to be aware of
optional
If you need an interpreter please let the reception desk know when you book the appointment. We will do our best to arrange this.
state kg or stone/pounds
state if cm, m or ft and inches
1 unit is a single measure of 40% spirit or half pint lager, beer or cider, small (275m) lower strength (4%) alcopop 2 units is standard glass (175ml) of 12% wine or pint of lager, beer or cider, 440 ml medium strength (4.5%) lager, beer or cider, double measure spirit 3 units is pint of medium(5%) lager, beer or cider, large glass (250 ml) wine, large bottle (750ml) alcopop 4 units is a large bottle (750 ml) high strength (5.5%) alcopop or 500 ml high strength (7.5%) lager, beer or cider.
Please enter a number greater than or equal to 0.
If you do not own a home blood pressure machine we encourage all patients over the age of 45 or with a history of high blood pressure to buy one. Alternatively once registered please come in and use our self-service blood pressure machine or to ask to borrow a blood pressure machine from the surgery.
Do you have a history of any of the follwoing
It can be several weeks before we receive your medical records from your previous surgery. Is there any other significant medical history or current conditions that your GP should be aware of in the meantime?
If YES please give details of relationship and state age if under 60.
Please state if any family history of Stroke, Asthma, High Blood Pressure, Bowel Cancer, Thyroid Problems, Maternal Hip Fracture, Breast Cancer, High Cholesterol, Diabetes, Osteoporosis. If YES please state relationship and any details.
If you are over 40 and 74 with no pre-exisiting health conditions you are entitled to an NHS health check every five years. Please let us know if you have had one of these. If YES please give date of last NHS Health Check.
Are you taking any current regular medication? If YES please list name of drug and dosage. Please send us a copy of your repeat prescription request form. If there are medications that you have that are not on the repeat list please ask your previous GP to print out a list of any acute medication that you are on and forward this to us.
We send prescriptions electronically directly to a convenient pharmacy. Please nominate the pharmacy where you would like your prescription sent.
If YES please give name relationship to that person and reason why they need help Are they also a patient of The Hart Surgery?
If YES please give name, relationship to that person. Are they also a patient of The Hart Surgery?
Please click yes if you can as we find it more efficent and cost effective if we can communicate with you electronically.
Please click yes if you can as we find it more efficent and cost effective if we can communicate with you electronically.
If YES please provide their name and the relationship (and contact details if they are not a patient at The Hart Surgery)
ie medicines, allergies and adverse reactions
Are you happy for your confidential patient information to be used for planning and improving health services or for healthcare research? (Type 1 opt out). IF NOT you need to register your dissent by visiting https://www.nhs.uk/your-nhs-data-matters/ or call NHS Digital Contact Centre 0300 303 5678 (Mon to Fri 9 am to 5 pm (excluding Bank Holidays))
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.