High Street Surgery

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Health Questionnaire


Thank you for taking the time to complete our Health Questionnaire. You will be guided through a number of pages which request basic medical information. The process wil only take a few minutes.

We will use the entries you make here to keep your medical record up-to-date.

General Information:

Patient Identification:

Firstname (1st 3 Chars): *

Surname (1st 3 Chars): *

Date of Birth (dd/mm/yyyy): *

 /   / 

Contact Information:

Home Number:

Mobile Number:

Languages Spoken & Ethnicity:

Languages Spoken: *



Do you regulary care for someone who is disabled or cronically ill ? *

No  Yes

Terms & Conditions:

Please confirm by ticking the box below that you have read and accept our Terms & Conditions for using this online facility to send us your Health Questionnaire:


How do I complete this form ?

Simply enter your details into each field, you can use the [tab] key to move between fields. When finished press the 'Continue' button.

Are my details secure ?

The Internet is not a secure medium. Please refer to our privacy page for further details. If after reading this you do not wish to use this Questionnaire, please call or write to us requesting a paper copy of the Questionnaire.

Other Notes:

All fields marked with * are mandatory.