TMG New Patient Questionnaire

Welcome to the Practice. Please help us by completing this questionnaire. Any information given is strictly confidential. It is collected to ensure that we treat all patients fairly and equally. It gives us the opportunity to meet all your needs both physically and emotional.

Last Updated: 20/02/2024

  • Personal Details

    Date of Birth
    For example, 15 3 1984
  • What To Do Next

    If you have not already done so, please submit a Patient Registration Form. This form IS NOT a registration form and is to help us gather information for new patients,.

  • Personal History

    Have you ever suffered from any of the following conditions? If anyone in your family suffers with any of the following, please provide details below.

  • Allergies

  • Medication

    Are you currently on any regular medication?
    Would you like your prescriptions to go electronically directly to your chosen pharmacy?
    If yes, which Pharmacy? (optional)
  • Your statistics

  • Smoking

    If you are a smoker and have the desire to stop please visit for a wide range of free support or ask for further information at reception or your local pharmacy.

    Please inform us of your current Smoking Status
    If you are an ex smoker what is the date you gave up (optional)
    For example, 15 3 1984
    Are you considering stopping smoking? (optional)
  • Alcohol

  • Next of Kin

    It is very helpful to have your next of kin or contact details but we are required to obtain consent before we can include them on your medical records. Please ask your chosen next of kin contact to complete this section.

  • In Case of Emergency

    Do you have a nominated person in case of an emergency? If details have not already been provided on this form we are required to obtain consent before we can include them on your medical records.

  • Power Of Attorney

    Do you have a Power of Attorney in place? (optional)
  • Proxy Access

    If you would like a third party to access/manage your medical record online and/or in person, please contact the surgery. 

  • Equity of Access Information

    This information is asked to ensure that every patient is treated equally and fairly. If you would prefer not to answer any of these questions please tick the ‘do not wish to complete’ box.

  • Carers

    If Yes to either of the below please ask our receptionist for a “Tell Your GP You Are a Carer” form.

    Are you a carer?
    Do you have a carer?
  • Military Veteran

    ENLISTMENT DATE: (optional)
    For example, 15 3 1984
    For example, 15 3 1984
  • Patient Participation Group (PPG)

    Membership is a great opportunity to influence services in our area. If you would like to be involved you can join our PPG. For more information please email or visit our website for further details

    I am interested in joining...
  • Data Systems

    1.         Summary Care Record

    The NHS in England has introduced the Summary Care Record, which will be used in emergency care.  The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.  Healthcare staff will ask your permission before they look at your record, except in certain circumstances for example if you are unconscious.  As a patient you have a choice—more information is available by visiting


    2.         Connecting Care Record

    In addition to the National Summary Care Record, your local NHS in Bristol, North Somerset and South Gloucestershire has developed a local shared record, called the Connecting Care Record.  Your Connecting Care record will contain more detailed information, such as diagnoses, medications and appointments, to support your treatment and care at services in your area.  This record will only be used to support your care locally.  It will ensure that the people caring for you have enough information to treat you safely and to co-ordinate your care.  Your Connecting Care Record will only be available to authorised health and social care staff who are directly involved in your care locally.  As with the Summary Care Record, they must have permission each time they view your Connecting Care Record.  As a patient you have a choice,


    3.         Local Record Sharing

    This is a local system that will enable your GP Practice to share your medical record with other GPs and healthcare providers to improve continuity of care.  The One Care agreement will provide access to your whole patient record.  It will only be shared with healthcare professionals who are treating you or administrative staff who book your appointments.


    Please be aware that the above information is only shared for your direct care


    4.         National Data Opt-Out – Data for Research and Planning

    Your health records contain a type of data called confidential patient information. This data can be used to help with research and planning. You can choose to stop your confidential patient information being used for research and planning. You can also make a choice for someone else like your children under the age of 13. Your choice will only apply to the health and care system in England. This does not apply to health or care services accessed in Scotland, Wales or Northern Ireland. To find out more visit you're happy with your confidential patient information being used for research and planning you do not need to do anything. Any choice you make will not impact your care. You can view or change your national data opt-out choice at any time by using the online service at or by calling 0300 3035678.

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