New Patient Registration & Health Questionnaire If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form. Step 1 of 3 33% Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number Optional First Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Female Male EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseFirst Spoken Language Town and Country of Birth Address Street Address Address Line 2 City Postcode Main Contact NumberHome Contact Number OptionalEmail Enter Email Optional Confirm Email Optional Can the practice send appointment reminders/important messages by text? or email? Yes No Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Address Line 2 City Postcode Name of doctor while at that address Address of previous doctor Street Address Address Line 2 City Postcode Are you ordinarily a resident in the UK? Yes No Your first UK address where registered with a GP Street Address Address Line 2 City Postcode If previously resident in UK, date of leaving Day Month Year Date you first came to live in the UK Day Month Year Date you first came to live in the UK Day Month Year European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? Yes Optional No Optional PATIENT DECLARATION for all patients who are not ordinarily resident in the UKDeclaration a) I understand that I may need to pay for NHS treatment outside of the GP practice b) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested c) I do not know my chargeable status I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me. A parent/guardian should complete the form on behalf of a child under 16. Full Name of person completing Relationship to patient (if applicable) Optional Date: Day Month Year DemographicsWhat is your current occupation? Employed Not Employed Self Employed Retired Student Other Prefer not to say Marital Status Single, never married Married Civil Partnership Divorced Widowed Separated Which of the following options best describes you? Heterosexual or Straight Gay or Lesbian Bisexual Prefer not to say In another way Sex and gender identity – Which one of the following best describes how you think of yourself? Male (including trans men) Female (including trans women) Non-binary Prefer not to say In another way Is your gender identity the same as the gender you were given at birth? Yes No Prefer not to say Please specify the ethnic group you consider you belong to English Welsh Scottish Northern Irish British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say What is your main religion? No religion Optional Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional Buddhist Optional Hindu Optional Jewish Optional Muslim Optional Sikh Optional Other religion Optional Communication NeedsDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language? DisabilityDo you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) No known impairment, health condition or learning difference Optional A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional A learning difficulty Optional Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional Deaf or hearing impaired Optional Blind or have a visual impairment uncorrected by glasses Optional An impairment, health condition or learning difference that is not listed above Optional Prefer not to say Optional Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalArmed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes No Do you have access to secure housing? Yes No What is your current immigration status? Asylum Seeker Optional Failed Asylum Seeker Optional CarersDo you have caring responsibilities? None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say Do you have a carer? Yes No Emergency ContactFull Name Relationship to you Contact NumberAre they your next of kin? Yes No Do you give us permission to discuss your medical records with them? Yes No About YouHeight Weight Blood Pressure (using the self-checking machine in Reception area if required) Smoking Status Current Smoker Ex Smoker Never Smoked What do you smoke? e.g. Cigarettes, Vape, CigarsHow many do you smoke per day? Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per week OptionalAlcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ 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? Never Less than monthly Monthly Weekly Daily or almost daily Do you have any significant family history we should be aware of? OptionalMedical HistoryMajor Illnesses OptionalPlease include datesPast Operations OptionalPlease include datesFamily History Illnesses OptionalPlease include datesDo you take any regular prescribed medicines or inhalers OptionalPlease specify if you have a preferred Chemist K’s Chemist, 120 Phoebe St, M5 3PH (next door to the surgery) Lloyd’s Chemist, 100 Regent Rd, M5 4QU (in Sainsbury’s Supermarket) Boots Chemist, Regents Park, M5 3TP. Other We routinely offer HIV screening would you be interested in being screened? Yes No Sight Good Poor Registered Blind Hearing Good Poor Partially Deaf Deaf Are you over 75 years old?The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.AllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include datesImportant Registration InformationFor anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations. You will soon receive an email from the practice with your log in details. These are confidential: It is your responsibility to ensure they can be received securely by email. Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service Before you apply for online access to your medical record, there are some other things to consider. Although the chances of any of these things happening are very small, you are asked that you have read and understood the following before you are given login details. Things to consider Forgotten history There may be something you have forgotten about in your record that you might find upsettingAbnormal results or bad news If your GP has given you access to test results or letters, you may see something that you find upsetting. This may occur before you have spoken to your doctor or while the surgery is closed, and you cannot contact them.Choosing to share your information with someone It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.Coercion If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.Misunderstood information Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.Information about someone else If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible. More information For more information about keeping your healthcare records safe and secure, we recommend that you read Protecting your GP Online Records and this helpful leaflet produced by the NHS in conjunction with the British Computer Society: Keeping your online health and social care records safe and secure I wish to have access to the following online services (please tick all that apply): Booking appointments Optional Requesting repeat prescriptions Optional Sending secure messaging Optional Access to detailed medical record Optional Proxy Access to records for family members who I care for with separate login details Optional I wish to access my online services and understand and agree with each statement (tick) I have read and understood the information provided by the practice Optional I will be responsible for the security of the information that I see or download Optional If I choose to share my information with anyone else, this is at my own risk Optional If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible Optional If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible Optional If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible Optional If I see something in my records that I am unsure of and have not yet been contacted by the surgery, I will wait until usual opening times and not contact the out of hours or emergency services Optional Please upload your ID to enable us to register you for online services OptionalMax. file size: 50 MB.Summary Care RecordThis record will contain summary 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 with 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 away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? Yes No Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323What happens to my information?Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year