Cadbury Heath Healthcare
New Patient Health Questionnaire
Welcome to Cadbury Heath Healthcare. Our aim is to provide you the best care possible to help you manage any existing health conditions and to prevent ill health in the future.
As a first step and to help us to get to know you better, please complete our health questionnaire as fully as you can. If anything is not clear, please ask.
We also encourage you to make an appointment for a New Patient check too
We ask all patients to provide 2 forms of Identification when registering – one with a photograph and the other with your address. Please check if you are not sure what is needed.
Personal Details
Title: …… Surname: ………………. / Forename(s): …………………………………Address: ………………………………………………………………………………………
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
Postcode: …………………………………………………………………………………….
Date of birth: ………………………………………………………………………………….
Telephone Nos.
Home:
Work:
Mobile:
Email address:
Have you been registered with this practice before? YES / NO
Do you look after anyone? YES / NO
Please give details:
Have you had an assessment of your needs as a Carer?
Please give details of other family members living at your address:
1. …………………………………………………………………………………………
2. …………………………………………………………………………………………
3. ………………………………………………………………………………………..
Please complete a separate form for each person wishing to register
Medical History
Do you suffer from or are you receiving treatment for any of the following conditions?Heart Disease / YES / NO / Heart Failure / YES / NO
Stroke / YES / NO / High Blood Pressure / YES / NO
Diabetes / YES / NO / Asthma / YES / NO
COPD / YES / NO / Emphysema/bronchitis / YES / NO
Thyroid Disease / YES / NO / Kidney Disease / YES / NO
Schizophrenia / YES / NO / Bipolar Affective Disorder / YES / NO
Epilepsy / YES / NO / Cancer / YES / NO
If NO and you are aged 40-74 would you like a free NHS Health Check? YES / NO
Please tell us about any serious illnesses, operations or accidents you have had in the past and when they happened.
Please give details of any regular medication you take (including the contraceptive pill)
1.
2.
3.
4.
5.
6.
Do you have any allergies (especially any drug allergy)? YES / NO
Is there any further information you feel your doctor should know?
Please let us know the name and address of your previous GP:
Ethnicity and Language
Please tick how you would describe your ethnicity:
White / A / BritishB / Irish
C / Any other White background
Mixed / D / White and Caribbean
E / White and Black African
F / White and Asian
G / Any other mixed background
Asian or British Asian / H / Indian
J / Pakistani
K / Bangladeshi
L / Any other Asian background
Black or Black British / M / Caribbean
N / African
P / Any other Black background
Other Ethnic Groups / R / Chinese
What is your first choice of language? ……………………………………………..
Healthy Living
Smoking
Do you smoke?? / YES / NOIf YES, how many cigarettes per day?
Would you like help to stop? / YES / NO
Are you happy for us to contact you for support to stop smoking? / YES / NO
If NO, have you ever smoked? / YES / NEVER
How many did you use to smoke?
When did you stop?
Exercise
Do you take regular exercise? / YES / NOIf YES, how would you describe your level of activity / Light / Moderate / Strenuous
“Moderate” is around 30 minutes, 5 times a week
Alcohol
Do you drink alcohol? / YES / NOIf YES, please complete the questionnaire
Units Guide:
Units per week: ______
Alcohol Questionnaire
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
1. / 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
2. / 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+
3. / 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
Please complete the following questions if your score was 5 or more
4. / How often in the past year have you found you were not able to stop drinking once you had started? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
5. / How often in the last year have you failed to do what was expected of you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
6. / How often in the last year have you needed an alcohol drink in the morning to get you going? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
7. / How often in the last year have you had a feeling of guilt or regret after drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
8. / How often in the last year have you not been able to remember what happened when drinking the night before? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
9. / Have you or someone else been injured as a result of your drinking? / No / Yes, but not in the past year / Yes, during the past year
10 / Has a relative/friend/doctor/ health working been con-erned about your drinking or advised you to cut down? / No / Yes, but not in the past year / Yes, during the past year
Scoring: 0-7 = Lower Risk, 8-15=Increasing Risk, 16-19=Higher Risk and 20+ = Possible Dependence
If you are concerned at all about your drinking and would like to speak to a doctor about this, please make an appointment
NHS SUMMARY CARE RECORD
NHS England are introducing a new electronic record called the Summary Care Record (SCR), which will be used to support your emergency care.
Introduction to Summary Care Records
Today, records are kept in all the places where you receive care. The places can usually only share information from your records by letter, email, fax or phone. At times, this can slow down treatment and sometimes information can be hard to access.
We are introducing Summary Care Records to improve the safety and quality of patient care. Because the summary Care Record is an electronic record it will give healthcare staff faster, easier access to essential information about you, to help provide you with safe treatment when you need care in an emergency or when your GP practice is closed.
About your Summary Care Record
If you decide to have a Summary Care Record it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had.
Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP Practice is closed.
Your Summary Care Record will also include you name, address, date of birth and your unique NHS number to help identify you correctly.
You may want to add other details about your care to your Summary Care Record. This will only happen if you ask for the information to be included. You should discuss your wishes with the healthcare staff treating you.
How will my Summary Care Records help me?
· Healthcare staff will have quicker access to information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had.
· This means they can provide you with safer care during an emergency, whey your GP Practice is closed or when you are away from home in another part of England.
How will you control who can see my Summary Care Record?
Healthcare staff who can see your Summary Care Record:
· Need to be directly involved in caring for you:
· Need to have an NHS Smartcard with a chip and passcode (like a bank card and PIN)
· Will only see the information they need to do their job: and will have their details recorded.
Healthcare staff will ask you permission every time they need to look at your Summary Care Record. I they cannot as you, for example if you are unconscious or in certain circumstances such as a court order, healthcare staff may look at your record without asking you. If they have to do this, they will make a note on your record.
How will you protect my confidentiality?
By law, everyone working for us or on our behalf must respect your confidentiality and keep all information about you secure.
We publish the NHS Care Record Guarantee for England. This says how the NHS will collect, store and allow access to your electronic records and your choices for how your information is stored and looked at. If you would like a copy, this can be obtained at www.nhscarerecords.nhs.uk
No matter how careful we are, there are always risks when information is held on computers as there is when they are held on paper. In every place we treat you there are people responsible for protecting your confidentiality. Ask your local NHS for more information.
What are my choices?
You can choose have a Summary Care Record or not to have a Summary Care Record:
Go to the section headed “what do I do now” to select your preferred option after reading the remainder of this document.
You can change your mind at anytime.
· If you choose not to have a Summary Care Record but then change your mind later we can still make one for you.
· If you choose after we have made your Summary Care Record that you not want it, you need to tell your GP practice. We will make sure that healthcare staff who try to look at your Summary Care Record will not be able to. We will only make your record available again if whoever wants to see it asks in writing and investigation has found it necessary.
· You can ask to have your record deleted, but that may not be possible if the record has already been used to give you care.
Children and the Summary Care Record
Children will automatically have a Summary Care Record made for them.
If you DO NOT want your child to have a Summary Care Record you will need to inform your GP practice. In some circumstances your GP may feel it is in your child’s best interests to have a Summary Care Record. For example, if your child has a serious allergy that healthcare staff treating your child should know about.
What do I do now?
If you are happy for to make a Summary Care Record for you, you do not need to do anything accept circle the YES below. We will automatically make one for you.
I would like a Summary Care Record YES
If you do not want us to make a Summary Care Record for you, please circle NO below
I do not want a Summary Care Record NO
Where can I get more information?
For more information about Summary Care Records and your choices:
· Phone the Summary Care Record Information Line on 0300 123 3020
· Contact your local Patient Advise and Liaison Service (PALS) www.pals.nhs.uk or
· Visit www.nhscarerecords.nhs.uk
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