Online Registration Form - Church View Medical Centre

New Patient Registration Form (GSM1 + Health Q’s)

Step 1 of 2

50%

Personal Details

Title

Mrs

Miss

Other

NHS Number: Optional

Surname:

First Names:

Prev Surname: Optional

Date of Birth

Day

Month

Year

Sex:

Male

Female

Ethnicity: Optional

Town and Country of Birth:

Address

Street Address Address Line 2 City Post Code Country

Telephone Number Optional

Mobile Number

Email Address

Please help us trace your previous medical records by providing the following information:

Previous Address

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional Post Code Optional Country Optional

Name of Doctor while at that address Optional

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

Are you from abroad?

Yes Optional

No Optional

Are you in the Armed Forces?

Yes Optional

No Optional

If you are from abroad:

Your first address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

If previously resident in UK, date of leaving Optional

DD slash MM slash YYYY

Date you first came to live in the UK Optional

DD slash MM slash YYYY

If you are from the Armed Forces:

Address before enlisting

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

Service or Personnel number Optional

Enlistment date Optional

DD slash MM slash YYYY

Discharge date Optional

DD slash MM slash YYYY

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance. Optional

If you need your doctor to dispense medicines and appliances:

Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist. Optional

I would have serious difficulty in getting them from the chemist. Optional

NHS Organ Donor registration:

Please tick as appropriate:

Any part of my body Optional

Or only my:

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Optional

Tick here if you have given blood in the last 3 years. Optional

Emergency Contact

Name:

Relationship: Optional

Contact Number:

Address

Street Address Address Line 2 City ZIP / Postal Code Country

I have filled in this form on behalf of

NEW PATIENT QUESTIONNAIRE

Please answer these questions to the best of your ability and hand this questionnaire into the receptionist. The information will be used to update your personal medical record.

Personal Details

Full Name

Address

Street Address Address Line 2 City Post Code Country

Place of birth

Date Of Birth

Day

Month

Year

Gender

Phone Number

Do you consent to receive communication (appointment reminders etc) from us via SMS?

Email Address Optional

Do you consent to receive communication (appointment reminders etc) from us via email? Optional

The Department of Health has asked us to record the ethnic origin, and first language, of all new patients. Please tick the box which most accurately describes you:

White – British Optional

White – Irish Optional

Other White background Optional

White/Black Caribbean Optional

White/Black African Optional

White/Asian Optional

Other mixed background Optional

Chinese Optional

Indian/British Indian Optional

Pakistan/British Pakistan Optional

Bangladesh/British Bangladesh Optional

Other Asian background Optional

Caribbean/British Caribbean Optional

African/British African Optional

Other Black background Optional

Other ethnic background Optional

Prefer not to say Optional

What is your first main spoken language? Optional

Marital status Optional

Occupation Optional

Health and Fitness

Height

Weight

How many times a week do you exercise?

What type of exercise do you do?

Smoking History

What is your smoking status?

How many cigarettes do you smoke a day?

If you want to stop smoking please ask us about our Stopping Smoking services.

When did you stop smoking?

DD slash MM slash YYYY

Medical Background

What illnesses have you had and when?

What operations have you had and when?

Do you have any medical problems at present?

Are you on any regular medication?

What medication?

Are you able to administer your own medication?

Please detail specific details?

Difficulty swallowing, opening containers etc..

Do you have any allergies?

Which Drugs/Medication?

What are your allergies?

Specific Needs

Please detail any specific needs you may have:

i.e. Speech, Hearing, Sight

Please state any physical disabilities you have?

Are you a carer?

Please state the contact details for the person you care for:

Are you cared for?

Please state the contact details for the person who cares for you:

Do you consent for us to contact your carer if we need to?

Alcohol Consumption

Do you drink Alcohol? Optional

How many units a week do you drink? Optional

How often do you have a drink containing Alcohol? Optional

How many units do you drink on a typical day? Optional

How often in the last year have you had 6 or more units (Female) or 8 or more units (Male) on a single occasion? Optional

SUMMARY CARE RECORD – your emergency care summary

NHS England has introduced the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.

GP practices are supporting Summary Care Records and as a patient you have a choice:

For more information talk to the Patient Advice and Liaison Service (PALS), GP practice staff, visit the website www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

Will you need a translator when you see one of our medical team?

Would you like to join our patient participation group?

The practice is committed to improving the services we provide to our patients. To do this it is vital that we hear from people about their experiences, views and ideas for making services better. By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean that we can keep you informed of opportunities to give your views and up to date with developments within the practice. If you are interested in getting involved please select yes and we will arrange for a sign up form to be given to you.

New Patient Registration Form (GSM1 + Health Q’s)

Personal Details

Please help us trace your previous medical records by providing the following information:

If you are from abroad:

If you are from the Armed Forces:

If registering a child under 5:

If you need your doctor to dispense medicines and appliances:

NHS Organ Donor registration:

NHS Blood Donor registration

Emergency Contact

NEW PATIENT QUESTIONNAIRE

Personal Details

Health and Fitness

Smoking History

Medical Background

Specific Needs

Alcohol Consumption

SUMMARY CARE RECORD – your emergency care summary

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE