Windmill Health Questionnaire V2

Last Updated: 20/07/2023

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984
    Preferred Contact Method

  • Information About You

    Do you need an interpreter?
    Ethnic Group
    Are you an asylum seeker?
    Accommodation
    Are you currently employed?
    What is your relationship status?

  • Next of Kin

    Relationship (optional)
    Title (optional)

  • Previous GP

  • Allergies

    Do you have any allergies or sensitivities?

  • Carers

    Do you have a carer?
    Are you a carer?

  • Women

    Are You Currently Using Any Form of Contraception?
    Are You Currently Pregnant?
    If Pregnant, Have You Attended Any Scans? (optional)

  • Smoking

    Do you smoke?
    If 'No', have you ever smoked? (optional)
    Would you like advice on giving up smoking? (optional)

  • Alcohol

  • Contacting You

    Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

  • Nominated Pharmacy

  • Online Access

    For options 1 and 2 below, please contact the reception team to setup your account If you require access to view your GP records (point 3 below) we will require a valid photo ID and proof of address.

    Please select below the access you require (optional)

  • Personal Data Sharing

    If you visit anywhere else for care within the NHS, such as a hospital, we would like to share your details with them (sharing (OUT). This also allows there to share any information with us which will allow up to see any treatments you have elsewhere (sharing IN). Please be aware anyone under the age of 18 is automatically shared due to safeguarding.

    Share your medical records OUT?
    Share your medical records IN

  • Signature

    Date
    For example, 15 3 1984

  • Please ensure you have complete the separate GMS1 form

    If you do not complete all the required forms we will not be able to register you as a patient. If you wish to sign up for online services, please complete the relevant form.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.