Skip to main
Tadley Medical Partnership
Holmwood Health Centre , Franklin Avenue ,
0118 981 4166
Morland Surgery, 40 New Road,
0118 981 4166
Home
Search
Language
Homepage
Opening Times
Contact Us Online
Meet the Team
Appointment
Medication
Home
Search
Language
Homepage
Opening Times
Contact Us Online
Meet the Team
Appointment
Medication
New Patients
Patient Record
Online Forms
Patient Participation Group
Update Your Patient Record
Last Updated: 30/12/2021
Your Details
Full Name
*
Date of Birth
*
Home Phone Number
*
Mobile Number
Email Address
*
Ethnicity
Ethnic Group
*
Please select an answer
White British
White Irish
White Other
Black British
Black Caribbean
Black African
Black Other
Asian Indian
Asian Pakistani
Asian Chinese
Asian Other
White & Black British
White & Black Caribbean
White & Black African
White & Asian
Other
Prefer not to answer
Height & Weight
Height, in cms
Weight, in kg
Blood Pressure
Smoking
Do you currently smoke?
*
Yes
No
If 'Yes', How many cigarettes do you smoke in a day? If you would like to stop smoking, support and advice is available from Smokefree Hampshire
1 to 9
10 to 19
20 to 39
40 or more
Alcohol
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.
MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?
*
Never
Less than monthly
Monthly
Weekly
Daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily
How often during the last year have you failed to do what was normally expected of you because of drinking?
Never
Less than monthly
Monthly
Weekly
Daily
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
No
Yes, on one occasion
Yes, more than once
Other Information
Are you a carer
Yes
No
If 'Yes', Name of Person caring for
Date of Birth
WHAT IS YOUR RELATIONSHIP TO THE PERSON BEING CARED FOR?
IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY
Yes
No
THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
*
I consent to the practice collecting and storing my data from this form.
I consent to the Practice sending me text messages concerning my direct medical care
I consent to the Practice sending me emails concerning my direct medical care and Practice information
Submit Form
Further Information
Homepage
Disability Access
Meet Our Team
Practice Policies
Additional Forms
Further Info
Staff Vacancies
Practice Update Blog and Newsletter
Opening Times & Find Us - The Practice is staffed 08.00 to 18.30. Access to both surgeries is restricted after 18.00.
×
Translate this website with google
This website uses cookies
We use cookies to improve user experience. Choose what cookies you allow us to use. You can
read more about our cookies
before you choose.
Strictly Necessary
Performance
Targeting
Functionality
Save & Close
Accept all
Decline all