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📋 What questions are on the Local Form?
📋 What questions are on the Local Form?
Abi Ford avatar
Written by Abi Ford
Updated this week

The Local Form, designed and built by Healthtech-1, allows you to ask tailored questions to meet local incentive needs and serve your new patients. You can check out the full list of questions below! 😄

The Local Form starts with these mandatory questions👇

Why are you registering today?

Patients can select one from the following options:

  • New to the country

  • Moved house

  • Dissatisfied with previous GP practice

  • Previous GP practice permanently closed

  • New nursing home or residential home resident

  • Attending university

  • Attending boarding school

  • A newborn baby

  • Prefer not to say

How satisfied were you with your previous practice?

Rating scale:

  • Very satisfied

  • Satisfied

  • Neither satisfied or dissatisfied

  • Dissatisfied

  • Very dissatisfied

Do you have any feedback for your previous practice?

  • Free text response for patient to answer

Here are the questions you can choose to ask your patients. Feel free to turn any question on or off through your Hub under under Settings > Local Form Settings.

Click on the arrow to the left of each question to view patient response options!

Main spoken language questions:

  • What is your main spoken language?

    • Patients can select one from a list of options.

  • About your main spoken language:

    • Free text response when the patient states their main spoken language is 'Other'.

Do you live in a residential care home or a nursing home?

Patients can select one from the following options:

  • No

  • Yes, residential care home

  • Yes, nursing home with qualified nurses on site

  • Yes, as a staff member

What is your religion?

Patients can select one from the following options:

  • Buddhism

  • Christianity

  • Hinduism

  • Judaism

  • Islam

  • Sikhism

  • Other

  • None

  • Prefer not to say

What is your sexual orientation?

Patients can select one from the following options:

  • Heterosexual or Straight

  • Lesbian

  • Gay

  • Bisexual

  • Other sexual orientation not listed

  • Not sure or undecided

  • Prefer not to say

  • Information not known

Do any of the following apply to you (options of special circumstances)?

Patients can select multiple from the following options:

  • Approaching end of life

  • Asylum seeker

  • Experiencing homelessness

  • Housebound

  • Refugee

  • Victim of domestic abuse

  • Or, none

Do you receive support for any other professional agency?

Patients can select multiple from the following options:

  • Probation services

  • Domestic abuse services

  • Adult social care services

  • Mental health services

  • Or, none

Who do you care for and how do you provide care for them?

We will only ask this if the patient stated that they are a young, foster, or unpaid carer.

  • Free text response

Would you like free carers advice and support?

We will only ask this if the patient stated that they are a young, foster, or unpaid carer.

  • Yes

  • No

Would you like free smoking advice and support?

We will only ask this if the patient stated that they smoke cigarettes.

  • Yes

  • No

Do you use a vape or e-cigarette?

  • Yes

  • No, but I used to

  • No, I have never used one

Blood pressure questions:

  • Do you have a measure of your blood pressure within the last 6 months?

    • Yes

    • No

  • What is your blood pressure reading? Please enter your recent blood pressure measurement taken in the last 6 months e.g., 120/80.

    • We will only ask this if the patient stated that they know their recent blood pressure reading.

      • Free text response (answer required in the above format)

How much exercise do you do?

Rating scale:

  • Exercise physically impossible

  • Avoids even trivial exercise

  • Enjoys light exercise

  • Enjoys moderate exercise

  • Enjoys heavy exercise

  • Competitive athlete

Pregnancy questions:

  • Are you pregnant?

    • We will only ask this if the patient stated that they are of the female sex.

      • Yes

      • No

  • What is your due date?

    • We will only ask this if the patient stated that they are pregnant.

  • Are you booked in with maternity services?

    • We will only ask this if the patient stated that they are pregnant.

      • Yes

      • No

  • Which maternity services are you booked in with?

    • We will only ask this if the patient stated that they are pregnant and booked in with maternity services.

      • Free text response

Smear testing questions:

  • Do you know the date of your last cervical screening (smear) test?

    • We will only ask this if the patient stated that they are of the female sex and are aged between 24-65.

      • Yes

      • No

      • This is not relevant for me

      • Prefer not to day

  • When was your last cervical screening (smear) test? The exact date is not important, just the month and year.

    • We will only ask this if the patient stated that they know the date of their last smear test.

      • Box to enter the date

Contraceptive devices/implants questions:

  • Do you use any of the following contraception?

    • We will only ask this if the patient stated that they are of the female sex and are aged over 13.

      • Hormonal coil - IUS (intrauterine system)

      • Non hormonal copper coil - IUD (intrauterine device)

      • Contraceptive implant

      • Any other contraception

      • No

  • Do you know the brand name of this contraception?

    • We will only ask this if the patient stated that they use a contraceptive device/implant.

      • Yes

      • No

  • What is the brand name of this contraception?

    • We will only ask this if the patient stated that they know the brand name of their contraceptive device/implant.

      • Hormonal coil - Jaydess

      • Hormonal coil - Kyleena

      • Hormonal coil - Levosert

      • Hormonal coil - Mirena

      • Non-hormonal copper coil - Ancora 375 Ag

      • Non-hormonal copper coil - Ancora 375 Cu

      • Non-hormonal copper coil - Copper T 380A

      • Non-hormonal copper coil - Cu-Safe T300

      • Non-hormonal copper coil - Flexi-T 300

      • Non-hormonal copper coil - Flexi-T + 380

      • Non-hormonal copper coil - GyneFix

      • Non-hormonal copper coil - Load 375

      • Non-hormonal copper coil - Mini TT 380 Slimline

      • Non-hormonal copper coil - Multiload Cu375

      • Non-hormonal copper coil - Multi-Safe 375

      • Non-hormonal copper coil - Multi-Safe 375 Short Stem

      • Non-hormonal copper coil - Neo-Safe T380

      • Non-hormonal copper coil - Novaplus T 380 Ag

      • Non-hormonal copper coil - Novaplus T 380 Cu

      • Non-hormonal copper coil - Nova-T 380

      • Non-hormonal copper coil - Optima T 380 Cu

      • Non-hormonal copper coil - T-Safe 380A QuickLoad

      • Non-hormonal copper coil - TT 380 Slimline

      • Non-hormonal copper coil - UT 380 Short

      • Non-hormonal copper coil - UT 380 Standard

      • Contraceptive implant - Nexplanon

      • Hormonal coil (IUS) - other

      • Non-hormonal copper coil (IUD) other

      • Contraceptive implant - other

  • Do you know the date when it is due to be removed?

    • We will only ask this if the patient stated that they use a contraceptive device/implant.

      • Yes

      • No

  • When is your contraception due to be removed? The exact date is not important, just the month and year.

    • We will only ask this if the patient stated that they know the date when it is due to be removed.

      • Box to enter the date

Do you have any family history of these conditions?

Patients can select multiple from the following options:

  • Asthma

  • COPD

  • Epilepsy

  • Heart Disease

  • Stroke

  • High Blood Pressure

  • Diabetes

  • Kidney Disease

  • Liver Disease

  • Depression

  • Thyroid

  • Cancer

  • None

If you have previously been registered with a UK Armed Forces GP, what role were you registered as?

We will only ask this if the patient stated that they have previously been registered with a UK Armed Forces GP. Patients can select from the following options:

  • Armed forces reservist

  • Active duty military

  • Member of military family

  • Family of active serving member of the Armed Forces Reserves

  • Royal Navy veteran

  • Royal Marines veteran

  • Army veteran

  • Royal Air Force veteran

  • I have not served in the UK Armed Forces

Armed forces enlistment questions:

  • What is your enlistment date to the Armed Forces?

    • We will only ask this if the patient stated that they have previously been registered with a UK Armed Forces GP.

  • What date did you or will you leave the Armed Forces?

    • We will only ask this if the patient stated that they have previously been registered with a UK Armed Forces GP.

What university do you attend?

We will only ask this if the patient stated that they attend university. Note: you must have turned on the applicable student questions on NHS profile manager first.

  • Free text response

What is the best way to contact you when it comes to your medical circumstances?

Patient can select multiple from the following options:

  • Home phone

  • Mobile phone (includes SMS)

  • Work phone

  • Video calling

  • Email

  • Letter to home address

  • Letter to temporary address

  • No preference

  • Prefer not to say

Can we contact you about updates at the practice?

Patients can select multiple from the following options:

  • Yes - email and text

  • Yes - text only

  • Yes - email only

  • No

Would you like to be part of our Patient Participation Group?

  • Yes

  • No

Would you like this practice to view data that is recorded about you at other NHS organisations?

We will only ask this if you use systmOne as a clinical system.

  • Yes

  • No

Would you like to share a more detailed history of your GP data with other NHS organisations?

We will only ask this if you use systmOne as a clinical system.

  • Yes

  • No

Would you like to be tested for HIV?

  • Yes

  • No

Would you like to be tested for chlamydia?

  • Yes

  • No

How satisfied are you with this registration process?

Rating scale:

  • Very satisfied

  • Satisfied

  • Neither satisfied or dissatisfied

  • Dissatisfied

  • Very dissatisfied

Would you like a question to be added? Click here to find out more. ✨

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