The form a new patient completes before or at their first appointment. It gathers contact details, GP, relevant medical history, medication and the reason they are coming, so the first session starts with the history already on the record.
It is written for any allied health practice. Add discipline-specific screening questions (red flags for MSK, a food diary prompt for dietetics) rather than asking everything of everyone.
The UK standards it rests on
UK GDPR data minimisation principle (Article 5)
Collect what you need for the care you provide and no more. Every extra question is special category data you then have to protect and retain.
UK GDPR Article 13 and ICO guidance on the right to be informed
When you collect information directly from a patient, you must tell them who you are, why you need it and how long you keep it. Usually done by linking a privacy notice.
UK GDPR Article 9 and the Data Protection Act 2018, Schedule 1
Medical history is health data, so it needs both a lawful basis and a special category condition. For clinical care that is usually the health care condition.
HCPC Standards of conduct, performance and ethics
Expects full, accurate records. A structured intake makes the history consistent between patients and clinicians.
Must include
Full name, date of birth, phone, email and address
Identifies the patient and lets you contact them about their care. Date of birth also distinguishes patients with the same name.
GP name and practice
Needed if you write to the GP, refer on, or have a safety concern.
Current medication and allergies
Affects treatment choices and is safety-critical for techniques such as acupuncture, manipulation or anything involving topical products.
Relevant medical conditions
A short checklist (diabetes, heart conditions, clotting disorders, osteoporosis, epilepsy, pregnancy) catches contraindications early.
Reason for visit and how long it has been going on
The presenting complaint frames the whole assessment.
Privacy notice reference and a signature confirming accuracy
Meets the right to be informed and makes clear the patient supplied the information.
Optional
Emergency contact
Worth collecting for older patients, post-surgical rehab or home visits. Ask whether the contact knows they are listed.
Previous treatment for this problem
Helps you avoid repeating what has already failed.
How they heard about you
Useful for your own marketing decisions. Keep it clearly optional.
Private medical insurance details
Only if you bill insurers directly. Collect policy and authorisation numbers on a separate insurance form.
Occupation and activity level
Relevant for MSK and sports work; not needed for every discipline.
The template
Replace anything in [square brackets]. Print it, save it as a PDF from the print dialog, or copy the text into your own document.
New patient information
[Practice name] · Please complete before your first appointment. All information is kept confidential.
Your details
Full name: [Full name]
Date of birth: [DD/MM/YYYY]
Address: [Address, postcode]
Phone: [Phone number]
Email: [Email address]
Your GP
GP name and practice: [GP name, practice name]
Your health
Are you currently taking any medication? Yes / No
If yes, please list: [Medication and dose]
Do you have any of the following? Diabetes / Heart condition / Osteoporosis / Epilepsy / Blood clotting disorder / Pregnancy / None of these
Any allergies or adverse reactions? [Details]
Any other conditions, operations or injuries we should know about? [Details]
Your visit
Main reason for your visit: [Describe the problem]
How long have you had this problem? [Duration]
Have you had any previous treatment for it? [Details]
How did you hear about us? (optional) [Source]
Declaration
The information I have given is accurate to the best of my knowledge. I will tell [Practice name] if anything changes.
How we use and store your information is explained in our privacy notice: [Link to privacy notice].
On paid plans, Atlacare's form library includes a ready-made New patient intake form with these sections, which you can add to your account and edit, and you can choose an intake form to send automatically by secure link when a new patient books, and the completed form is saved to their record.
Atlacare