Mill Street Surgery Registration Form
Please fill out the form to the best of your ability, making use of the Guidance Notes prove
Name (True or Preferred) / Preferred Form of Address *
Your answer
Title: *
Your answer
Usual/Preferred Form (if your preferred or usual form has access requirements, please give details below)
Your answer
Contact Information (If a rite is required to summon you to appointments, please give details below or in supporting docs)
Your answer
Current Address (if preferred, please indicate the boundaries of your range on the map provided) *
Your answer
Previous GP Name & Address *
Your answer
Allergies/Intolerances/Aversions *
Your answer
Elemental Affinity Assessment *
Poor/Fatal
Fair/Not Preferred
Satisfactory/Ambivalent
Very good/Strong Preference
Excellent/Vital
Earth
Water
Air/Aether
Fire
Humour Assessment *
Lifestyle Assessment (Please read the Guidance Notes provided and answer honestly) *
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I engage in the approporiate levels of activity for my Kith and Kin
My diet closely matches the healthy eating guide for my Kith and Kin
I do not regularly exceed the recommended/safe/legal number of units of Recreational Depressants for my Kith and Kin
I do not regularly exceed the recommended/safe and legal limits of Recreational Stimulants for my Kith and Kin
I do not regularly exceed the recommended/safe and legal limits of Recreational Hallucinogens for my Kith and Kin
If you answered Disagree/Strongly Disagree to any of the above, please complete the following section:
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I have lost time as a result of my recreational indulgences
I am prone to violent outbursts when over-indulging
I have woken up covered in blood that I could not explain
Other people express concerns about my recreational habits
I myself have concerns about my recreational habits
Do you consent to Mill St Surgery keeping an aura sample on file?
Please indicate your preferences in the event of your unnatural death *
Emergency Contact Information
Your answer
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