Please complete all pages in FULL using BLOCK capitals (Admin Read code: XacWQ)
: Xab9D )
Surname
First Names (in full)
Previous Surnames
Title: Mr Mrs Miss Ms Male Female
Date of Birth (day/month/year)
NHS Number (if known)
Town & country of Birth
Address
Telephone number: Work number:
Mobile number:
Email address:
Your previous address in UK
Name of previous Doctor
while at that address
Address of previous Doctor
Your first UK address where
Registered with a GP
If previously resident in UK Date you first
date of leaving came to UK
Addresss before enlisting
Enlistment date
Are you a carer? Yes NoDo you have a carer? Yes No
If yes, please tell us the name & address of your
Carer:
Are you happy for us to contact your carer Yes No
about you?
In general, do you have any health problems that require you to limit your activities? Yes No
In general, do you have any health problems that require you to stay at home? Yes No
Do you regularly use a stick, walker or wheelchair to get about? Yes No
In case of need, can you count on someone close to you? Yes No
Do you need someone to help you on a regular basis? Yes No
Please provide details if the person is different
from the information you have provided as your carer.
Please enter your height & weight:
Height: / Weight:Do you smoke: Yes No If yes, do you
smoke: Cigarette Cigars Pipe
Are you an ex-smoker? Yes No When did you give up?
How many cigarettes/ <1/day 1-9/day 10-19/day 20-39/day 40+/day
cigars do you smoke
daily?
If you smoke a pipeWould you like help Yes No
how many ounces ato quit smoking?
week?
Please complete the attached Alcohol Screening Tool questionnaire.
Do you exercise: Yes No If yes, please answer the following questions
What exercise do you do?
How often do you exercise?
Are you currently, or think you may be Yes No
pregnant?
Do you have any children? Yes No If yes, how many?
Which method of contraception (if any) are
you using at present?
Have you had a cervical smear test? Yes No If yes, what was the
result?(if known)
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.
Any of my organs and tissue or
Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body
Signature to confirm agreement to organ/tissue donation is at the bottom of this form.
For more information please ask at reception for an information leaflet or visit the website or call 0300 123 23 23
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Tick here if you have given blood in the last 3 years
Signature to confirm consent to inclusion on the NHS Blood Donor Register at the bottom of this form.
For more information, please ask for the leaflet on joining the NHS Blood Donor Register. My preferred address for donation is (only if different from above eg your place of work)
……………………..………………………………………………………………… Post code: ………………….
Please indicate your ethnic origin:
British or mixed British Irish African Caribbean Indian Pakistani
Bangladeshi Chinese Other (please state):
Decline to state
Name: Tel. contact
number:
Relationship:
To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments). Please read the accompanying leaflet which details what part of your record is extracted and how it is used to help other NHS organisations.
If you wish to OPT OUT please complete the form found with this leaflet.
Where you have provided information on how to contact you, can you confirm you are happy for Royal Manor Health Care to contact you by the following:
By email Yes No By text Yes No
I confirm that the information I have provided is true to the best of my knowledge.
Signed:Date:
Signature of patient Signature on behalf of patient
Do you have a preference for a particular GP at the practice? Yes No
This is one unit of alcohol…
…and each of these is more than one unit
AUDIT – C
Questions / Scoring system / Your score0 / 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 - 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
Scoring:
A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.
Score from AUDIT- C (other side)
Remaining AUDIT questions
Questions / Scoring system / Your score0 / 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 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence
TOTAL Score equals
AUDIT C Score (above) +
Score of remaining questions
BACKGROUNDFor a number of years, work has been going on to improve the way that medical records are made available to treating clinicians. As a result of this work we are now able to share clinical information between certain health professionals.
This means that, with your consent, we are able to share your medical records with those in the NHS who are involved in your care. NHS staff can only access shared information if they are involved in your care and being an electronic service an audit log is maintained showing when and who accessed medical records.
This helps clinicians to make decisions based upon a wider knowledge of you and also helps to reduce the number of times that you or your family members are asked the same question. In short it assists clinicians to provide more ‘joined up care’.
We already share records of children for child protection reasons and patients who are under the care of the District Nursing team.
IF I AGREED, WHO COULD SEE MY RECORDS?Clinicians treating you, who have access to the same system, can view and in some cases update your medical records. Locally this includes the Walk-In Centre, many departments at local hospitals (including A&E) and community services, such as the District Nursing team. It is anticipated that over time more health services will be able to us this system to access records, if appropriate.
Clinicians outside of the surgery who wish to access your medical records will ask for your permission to do so and will need to have been issued with a NHS Smartcard – this is a ‘chip and pin’ card, similar to a bank card.
CAN I CHOOSE WHO SEES MY RECORD?Yes you can – there are two levels of consent. The first is to agree to sharing your medical records OUT of the Practice. This is your agreement that records maintained by your GP can be seen, subject to your authority at the time, by clinicians working outside of the surgery. The second is agreeing to share your records IN. This means that your GP can see the records made by other health professionals who have access to EDSM.
However, as the treating clinician needs to ask your permission to see the records at the beginning of each period of care you are in control of who can see your medical information.
WHAT CAN I DO IF I DON’T WANT TO ALLOW ACCESS TO MY RECORDS?As we feel this access will enhance patient care we will automatically ‘opt you in’ to both parts of the scheme. If you prefer not to be then please mention it to a member of the reception team. You are free to change your mind at any time.
I CAN SEE THE BENEFITS OF THE OTHER PEOPLE TREATING ME SEEING MY NOTES, BUT WHAT IF THERE IS A MATTER THAT I WANT TO STAY JUST BETWEEN ME AND MY DOCTOR?You can ask for any consultation to be marked as ‘private’. This means that viewing is restricted to the surgery, but allows the rest of the record to be viewed by whoever else is treating you. It is your responsibility to ask for a consultation to be marked as ‘private’.
HOW IS THIS DIFFERENT FROM PREVIOUS ARRANGEMENTS?In the past other NHS Services are able to see your current medications and the drugs that you are allergic or sensitive to via a Summary Care Record (SCR). This new system will allow your full record to be seen.
CAN I CHANGE MY MIND?Yes, you can always change your mind and amend who you consent to see your records. For instance, you can decline to share your records out from the surgery, but if you built up a relationship with a physiotherapist who was treating you and they asked you if they could look at an x-ray report, you could give your consent at that point for them to view your records.
You will be referred back to us to change your preference, so the physiotherapist treating you should – with your permission – be able to see your records at the time of your next appointment.
IF I DECLINE – WHAT HAPPENS IN AN EMERGENCY?In the event of a medical emergency, for instance, if you were taken unconscious to A&E, and the clinician treating you feels it is important to be able to see your medical records, he is able to override any consents set. However, the doctor has to give a written reason for doing so. Where this happens an audit is undertaken by the local Caldicott Guardian (the person with the overall responsibility for Data Protection compliance).
CAN ANYONE ELSE SEE MY MEDICAL RECORDS?Not unless you give your written consent for this to happen. On a daily basis we get requests from insurance companies to either have copies of medical records or excerts from patient’s medical records. This requires your signed consent as it has not been requested to treat/care for you. Occasionally we are asked for information from your medical records for legal reasons, again, this has to be done with your written consent or, in very exceptional circumstances, by Court order.
ANY QUESTIONS?If you have any questions, please speak to reception. If necessary the receptionist will arrange for another member of the team to give you a call.