Wellsbourne Healthcare Community Interest Company

Your local GP surgery in East Brighton

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New Patient Health Questionnaire


To complete your registration with us, YOU MUST now fill in this Health Questionnaire. The Health Questionnaire is compulsory for registering you as a new patient. Please give us as much information as you can.

Form Instructions

Please note that we will not respond to any medical information or questions received via this form.

The information you supply us will be used lawfully, in accordance with the Data Protection legislation and GDPR.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice.

Are my details secure?

The internet is not a secure place, however, we have gone to great lengths to make sure the information you submit to us is as secure as possible.

This website runs within a secured connection (256-bit SSL). So any information entered into the system is transmitted in encrypted form (you will see the little lock symbol in your browser address bar to confirm this). Details are transferred to your practice via a TLS-encrypted connection to the NHS email system.

Other Notes:

All fields marked with * are mandatory.

Surgery Contact Details

Wellsbourne Healthcare CIC

179 Whitehawk Road
East Sussex
BN2 5FLTelephone: 01273 005444

New Patient Health Questionnaire
Please tell us your Ethnic Origin
Are they a patient at Wellsbourne Healthcare?
Is the person registering as a new patient aged under 16?
Do they have a regular social worker or health visitor?
Would you like to sign up to our text messaging service so we can send you appointment reminders, test results or the important messages by text without delay? *
Would you like online access to your health record? You can see your record, book appointments and request repeat prescriptions online. It is quick, easy and will save you lots of time. *
Would you like to receive our practice newsletter, once a month by email, keeping you up to date with practice news, services and opening times?
About You
Lifestyle – do you smoke cigarettes or tobacco?
Lifestyle – do you drink alcohol?
Do you have any repeat prescriptions? *

Maximum file size: 5MB

Your chosen pharmacy. We operate an electronic prescription service from the surgery to a pharmacy of your choice. This allows us to send your prescription electronically so it will be ready for you to collect as quickly as possible. If you would like to make use of this service, please tell us your pharmacy below
Do you give your permission for the Extended Hours Service to access your medical records?
Would you be willing to join our Patient Reference Group and have a say in what the practice does in the future?
The Patient Reference Group is very valuable to us. We contact subscribers from time to time by email for feedback on planned services and research projects. No expertise is needed. You can respond only when it suits you. You can opt in or out at any time.
Do you speak English?
Can you read English?
Do you have a carer?
Do you look after anyone else who has a disability or long-term illness?
Summary Care Record. With your permission (and only with your permission), we can prepare a Summary Care Record to be used if you ever need emergency care. The record contains information about your medicines, allergies, and bad reactions to drugs, to ensure those caring for you have enough information to treat safely. Your Summary Care Record will be available to authorised healthcare staff only, providing your care anywhere in England, and they will ask your permission before they look at it. This means that if there’s an accident or illness, healthcare staff will have immediate access to important information about your health. A Summary Care Record will automatically be created for you unless you wish to opt out. If you do wish to opt out, please indicate this here