New Patient Questionnaire Form - College Lane Surgery

New Patient Questionnaire V3

Background Details

Contact Details

NHS Number *

Full Name (including any middle names) *

Gender *

Male

Female

Previous Surname (if applicable)

Date of Birth *

Address *

Home Telephone

Work Telephone

Mobile Number (I consent to be contacted by SMS on this number) *

Email Address (I consent to be contacted by email at this address)

Have you been registered in the NHS before? *

Yes No

If no, please state date you entered the UK

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details. If you do not consent to being contacted by SMS or Email, please tick here:

SMS

Other Details

Communication Needs

Carer Details

Are you a carer? *

Yes - Informal/Unpaid Carer

Yes - Occupational/ Paid Carer

Do you have a carer? *

Yes No

If yes please give details (Name, Tel, Relationship. Only add carer's details if they give their consent to have these details stored on your medical record.)

Armed Forces

Have you ever served in the Armed Forces? *

Yes No

Are you currently serving in the Armed Forces? *

Yes No

Are you currently a Reservist within the Armed Forces? *

Yes No

Do you have any immediate family (parent/guardian/spouse/dependant) serving in the Armed Forces? *

Yes No

If Yes, please state relationship:

Your Measurements

Height (metres/cm) *

Weight (kg) *

Waist Circumference (cm)

Blood Pressure

Women Only: Are you currently pregnant or think you may be?

Yes No

If you are pregnant, what is your expected due date?

Medical History

Family History

Allergies

Please record any allergies or sensitivities below: *

Alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Please enter your score for the alcohol questions answered above: *

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above. How often during the last year have you found that you were not able to stop drinking once you had started?

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above. How often during the last year have you failed to do what was normally expected from you because of your drinking?

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above. How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above. How often during the last year have you had a feeling of guilt or remorse after drinking?

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above.Have you or somebody else been injured as a result of your drinking?

Only complete the question below if you scored 5 or more on the alcohol questions 1-3 above. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Smoking

For further information, please see www.nhs.uk/smokefree

Do you smoke? *

Do you use an e-Cigarette? *

How many cigarettes did/do you smoke a day? *

Would you like help to quit smoking? *

Yes No

Further Details

Named Accountable GP - During the registration process you will be allocated a named accountable GP. You are however entitled to make an appointment to see any GP of your choice, subject to availability.

Electronic Prescribing - If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:

Patient Participation Group - We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services. Meeting dates are available on our website. Would you like to be involved in our Patient Participation Group? *

Yes No

Signature

Signature - I confirm that the information I have provided is true to the best of my knowledge. *

Signed on behalf of patient

Name *

Date *

Checklist

Please ensure the following are provided so that your registration can be completed successfully.

Please ensure the following are provided so that your registration can be completed successfully: *

Completed & Signed Above Form

Completed & Signed GMS1 Form

Photo Proof of ID e.g. Passport, Photo Driving License or Photo ID Card

Proof of Address e.g. Bank Statement, Utility Bill or Council Tax from within the last 3 months

Sharing Your Health Record

What is your health record? Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies. Why is sharing important? Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you: • Sharing your contact details - Ensures you receive any medical appointments without delay • Sharing your medical history - Ensures emergency services accurately assess you if needed • Sharing your medication list - Ensures that you receive the most appropriate medication • Sharing your allergies - Prevents you being given something to which you are allergic • Sharing your test results - Prevents further unnecessary tests being required Is my health record secure? Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. Can I decide who I share my health record with? Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained. Can I change my mind? Yes. You can change your mind at any time about sharing your health record, please just let us know. Can someone else consent on my behalf? If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you. What about parental responsibility? If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision. What is your Summary Care Record? Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future. How is my personal information protected? College Lane Surgery will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team For further information about your health records, please see: www.nhs.uk/NHSEngland/thenhs/records For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters

Do you consent to your GP Practice sharing your health record with other organisations who also care for you? *

Do you consent to your GP Practice viewing your health record from other organisations that care for you? *

Your Summary Care Record (SCR) - Do you consent to having an Enhanced Summary Care Record with Additional Information? *

Yes (recommended option)

Signature *

Signed on behalf of patient *

Name *

Date *

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Page last reviewed: 07 April 2021
Page created: 20 January 2021

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New Patient Questionnaire V3

New Patient Questionnaire V3

Further Information