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 needs.

Last Updated: 19/08/2020

Your Contact Details

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.




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.

Your statistics


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.


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

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.

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.

Patient Email Group (PEG) / Patient Participation Group (PPG)

We want to ensure our patients are involved in the decisions about the range and quality of services provided by the practice. This can be done as a PEG (email) or in person (PPG). See website for further details

Data Systems

You can find more information about our data systems and policies on our website. You can opt out of your data being transferred out of the Practice for any of these schemes. If you wish to opt out of any of the above please tick the relevant options, sign below and hand the form to reception.