New Patient Registration Form

NEW PATIENT REGISTRATION FORM

Date: ------/------/------

TITLE: MR MRSMsMISS DR OTHER; ------

NAME:------D.O.B.:------/------/------

ADDRESS: ------

------

TEL NO: HOME: ------MOBILE:------

I CONSENT TO BE CONTACTED BY SMS MESSAGES: YES: NO:

NEXT OF KIN: NAME:------RELATION------

ADDRESS: ------

TEL NO: HOME: ------MOBILE:------

ETHNIC ORIGIN:

/ British / / White / Asian / / Other Asian
/ Irish / / Other mixed / / Caribbean
/ Other White / / Indian/British / / African
/ White/Black Caribbean / / Pakistani/British / / Other Black
/ White/Black African / / Bangladeshi/ British / / Chinese

MARITAL STATUS: Single Married Separated Divorced WidowedCohabiting

PLACE OF BIRTH: ------

LANGUAGE SPOKEN: ------

RELIGION: ------

OCCUPATION: ------

HEIGHT: ------: Meters

WEIGHT: ------: Kilograms

Please Circle “YES” or “NO” to any of the following medical conditions you may have:

DIABETES YES/NOHEART DISEASE YES/NO

ASTHMA YES/NOEMPHYSEMA YES/NO

HYPOTHYROIDISM YES/NO EPILESPSY YES/NO

STROKE YES/NO HYPERTENSION YES/ NO

CANCER YES/NO MENTAL HEALTH PROBLEMS YES/NO

DEPRESSION YES / NO

ANY OTHER MEDICAL PROBLEMS/OPERATIONS:

------

ALLERGIES:-YES/NO ------

CURRENT MEDICATION AND DOSE:(please attach list of regular medications)

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LIFESTYLE;

ALCOHOL:Do You Drink ALCOHOL:YES/NO:

If YES;

Pints of BEER/CIDER/LAGER per week: ------

Bottles of WINE per week : ------

Measures of SPIRITS per week : ------

Never Smoked Tobacco: /
Ex - Smoker: / / when stopped:------
Smoker : / / Cigarettes/Pipe per day:------

SMOKING:

FOR STAFFUSE ONLY: If smoker, has smoking cessation advice been given: YES / NO

Summary care record consent YES / NO

What does it mean if I DO NOT have a Summary Care Record?

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.

(If you choose to opt out please ask for opt out form from reception)

Patient Online Services YES / NO

(Please see enclosed Online Service Leaflet)

WOMEN ONLY:

Number of pregnancies: ------Contraception: YES/NO

Date of last cervical smear: ------/------/------Date of last breast screen: ------/------/------

CHILDREN UNDER 16 YEARS OR OTHERS IN FULL TIME EDUCATION:

Name of school attending: ------

IMMUNISATIONS: - (For children, Please attach copy of immunization record);

------

FAMILY HISTORY: (Any family history of following conditions- PLEASE STATE RELATION)

DIABETES YES/NO: ------

HEART DISEASE YES/NO: ------

ASTHMA YES/NO: ------

EMPHYSEMA YES/NO: ------

HYPOTHYROIDISM YES/NO: ------

EPILESPSY YES/NO: ------

STROKE YES/NO: ------

HYPERTENSION YES/NO: ------

CANCERYES/NO: ------

ANY OTHER PROBLEM ------

Any other relevant information that you think would help us:

------

For patients aged 16 and over continue with the Alcohol Consumption Questionnaire overleaf.

Alcohol Consumption Questionnaire (AUDIT-C)

Questions / Scoring system / Your score
0 / 1 / 2 / 3 / 4
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 - 8 / 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

Scoring:

A total of 5+ indicates increasing or higher risk drinking.

An overall total score of 5 or above is AUDIT-C positive.

NOTE: If your score exceeds 5+ please continue with remaining Questions below

Questions / Scoring system / Your score
0 / 1 / 2 / 3 / 4
How often during the last year have you found that you were not able to stop drinking once you had started? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Have you or somebody else been injured as a result of your drinking? / No / Yes, but not in the last year / Yes, during the last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? / No / Yes, but not in the last year / Yes, during the last year

Scoring:

0-7 / Low Risk / 8-15 / Increasing Risk
16-19 / Higher Risk / 20+ / Possible Dependence

Broadway Medical Centre

General Practitioners
Dr Moazzam Chaudhary
MBBS, FRCSI, FACS, MRCGP, PG.Dip.Urol
Dr Saadia Rehman
MBBS, MRCP, MRCGP
Practice Managers
John Snaith & Razia Chaudhary / / 164 Great North Road
Gosforth
Newcastle upon Tyne
NE3 5JP
Tel 0191 2135005
Fax: 0191 2133729

Welcome to Broadway Medical Centre.

Opening times are:

Monday – 8am-6pm

Tuesday - 8am-6pm

Wednesday – 8am- 6pm

Thursday – 8am-1pm

Friday - 8am -6pm

Late night surgery on Monday evening 6.30pm – 7.45pm (to accommodate students and workers)

Please remember to cancel any unwanted appointments 24 hours prior to your allocated time so that other patients can be accommodated.

We offer 3 types of appointments:

Appointments that can be booked in advance:

On the day appointments which are released at 8am for that day:

Telephone appointments which can be booked in advanced or before 11am on the required day:

In addition special emergency appointments may be made for patients at the discretion of the duty Doctor

Appointments can be made with the practice nurse on Monday, Tuesday, Wednesday and Thursday.

Please check with reception as days and times may vary.

Dr Chaudhary is your named GP. You have a choice and this does not prevent you from seeing any GP at the surgery.

RECORD SHARING

INFORMATION IS ONLY SHARED BETWEEN HEALTHCARE PROFESSIONALS WITHIN THE NHS