Skip to content
Askalot

← All Other templates

Questionnaire template

New Patient Registration

Registers new patients with basic details, allergies, family history, lifestyle factors and contact information.

Preview

Other · Registration forms. All Other templates

Questions in this template

About You

  1. Welcome to our practice. Please complete this form so we can prepare your record and plan your care.

  2. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

  3. In what year were you born?

    A number from 1900 to 2026

Medical History

  1. Are you aware of any allergies you have?

    Choose one:

    • Yes
    • No
    • Not sure

  2. Please list your allergies, including medicines, foods or anything else.

    Condition: Only for patients with known allergies

    Open answer

  3. Has a parent, sibling or child of yours been diagnosed with a long-term illness?

    Choose one:

    • Yes
    • No
    • Not sure

  4. Which illness was it, and how is that person related to you?

    Condition: Only when a close relative has a long-term illness

    Open answer

Lifestyle

  1. Which of these best describes your smoking status?

    Choose one:

    • Current smoker
    • Former smoker
    • Never smoked

  2. In a typical week, how often do you take part in physical exercise?

    Choose one:

    • Never
    • Less than once a week
    • 1-2 days a week
    • 3-4 days a week
    • 5 or more days a week

Contact Details

  1. What is your home address?

    Open answer

  2. How would you prefer us to contact you?

    Choose one:

    • Phone
    • Email

  3. Please enter the phone number or email address we should use.

    Open answer