GP Online Questionnaire

GP ONLINE QUESTIONNAIRE

First Name

Last Name

Date of Birth

Phone/Mobile

Address

Address Line 1

Address Line 2

City

Postcode

Country

GP Name

GP Practice

Do you smoke?

Alcohol intake (units per week)

Occupation

Drug History

Height

Weight

if yes, please provide additional information

Additional notes - family member, age etc

Are you currently on any medication?

Yes

List the medication you are currently taking.

I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge.

Signature

Sign Here

18/06/2026