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GP signature:

NEWINGTON ROAD SURGERY

Dr A Akyol Dr I Ali Dr N Mohammed Dr E A Speller

100 Newington Road

Ramsgate, Kent, CT12 6EW

Tel: 01843 595951 Fax: 01843 853387

NEW PATIENT QUESTIONNAIRE

PERSONAL INFORMATION:

Sex (please circle) / Male/Female
Title (please circle) / Mr/ Mrs/ Miss/ Ms/ Dr/ Other
Surname
Previous Surname(s)
First Name
Date of Birth
Age
NHS Number
Occupation

ADDRESS:

House Name or Flat Number
Number and Street
Village
Town
Postcode
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Email Address
Sheltered Housing Access Code
Previous Address in UK
(or date entered country)
Previous GP (name and address)
Do you have a carer? / Yes/ No
If yes who is your carer?
Are you a carer? / Yes/ No
If yes who do you care for?

NEXT OF KIN:

Name
Address
Telephone number

The following information is requested to help us monitor and improve the care we give and to ensure that the care we provide does not discriminate in any way.

What is your first language? ………………………………......

Do you require an interpreter? Yes/No

ETHNIC BACKGROUND: Please tick one box which best describes you.

British / Irish
White & Black Caribbean / White & Black African
Indian / Pakistani
Bangladeshi / Chinese
Irish / Other White
Other Black ethnic group / Other Asian ethnic group
Not willing to inform / Other (please describe)

FAMILY HISTORY: Have you or any family members had any of the following?:

Heart attack or heart disease under 60? / Yes/ No
If so who? (please state if on mother’s or father’s side)
Heart attack or heart disease over 60? / Yes/ No
If so who? (please state if on mother’s or father’s side)
High blood pressure? / Yes/ No
If so who? (please state if on mother’s or father’s side)
Stroke under 60? / Yes/ No
If so who? (please state if on mother’s or father’s side)
Stroke over 60? / Yes/No
If so who? (please state if on mother’s or father’s side)
Diabetes? / Yes/ No
If so who? (please state if on mother’s or father’s side)
Bowel cancer? / Yes/ No
If so who? (please state if on mother’s or father’s side)
Age bowel cancer diagnosed
Other health problems affecting you. Please list.

SMOKING:

Do you smoke? / Yes/No/Stopped/Never
If yes would you like to stop? / Yes/ No
How many do you smoke a day?
If stopped when?

ALCOHOL:

Do you drink alcohol? / Yes/ No
If yes how much per week?

Also, if you have replied yes and are over 16 years of age, please complete separate Alcohol AUDIT attached.

MEDICATION: Are you on any medication? Yes/No

If yes, please attach a copy of your last repeat prescription slip. If this is not available, please list all details below:

Drug Name / Strength / Dosage

ALLERGIES: Do you have any allergies? Yes/No

If yes, please give details:

WOMEN ONLY:

Have you had a smear in the last 3 years? / Yes/ No
If yes please give date
Do you use contraception? / Yes/ No
If yes please describe / Pill/ coil/ condoms/ injection/ implant/ other

IMMUNISATION HISTORY FOR CHILDREN UNDER 5:

Immunisation / Date given / Immunisation / Date given

If you have any queries or need help filling in these forms please do not hesitate to ask at reception.

Please complete and return these forms (including thePatient Contract), together with the required acceptable proof of identification (please see below) to reception.

ACCEPTABLE IDENTIFICATION

Before proceeding with your application, we will need to verify your ID.

Please provide: 1 Document from List A and 1 Document from List B.

List A – Photo ID:

  • A valid passport.
  • A valid HM Forces Identify card with signatory’s photograph.
  • A valid UK or EU photograph driving license.
  • EU Member of State Card.

NB: If you do not have any photo ID we will require a birth certificate plus evidence of any subsequent change(s) of name, if applicable.

List B – Proof of address:

  • A receipted utility bill less than 3 months old.
  • Council tax bill less than 3 months old.
  • Council rent book showing the rent paid for the last 3 months.
  • A bank or mortgage statement not more than 3 months old.
  • Tenancy agreement letter of current address.

You will be notified in writing if you have been accepted to join our Surgery and if you are over the age of 16, you will be asked to book a New Patient Appointment. It is important that you book and attend your New Patient Appointment.

PATIENT CONTRACT

This document sets out information about the manner in which we run the services at Newington Road Surgery. We would ask you to read this document and then make an appointment with the Practice Nurse for a new patient check.

Telephone Consultations

A triage by the receptionists will be undertaken. There is no need to be concerned because all the information is treated with strict confidentiality.

When making contact with the Surgery by telephone we would ask you to keep it as brief and to the point as possible in order that other patients can also make contact with us.

For results please telephone after 3.00pm.

Consultations

Consultation time is precious; so try not to bring too many problems to one appointment. If the Doctor had to deal with an emergency your appointment may be delayed. If this happens you will be offered the opportunity of either waiting or re-booking.

Cancelling Appointments

If you make an appointment to see your GP and then are unable to attend, please ring the surgery beforehand. If possible, please ring at least 24 hours before, so that we can make the appointment available to another patient.

Patients who fail to attend for 3 appointments within a 6 month period without cancelling will be asked to register with another Practice.

Late Attendance

Please make every effort to attend the Practice at the time of your appointment. Patients who attend more than 5 minutes late may be asked to either wait until the end of the surgery or make a further appointment for another day. The Doctors do endeavour to run their surgery to time.

Repeat Prescriptions

The Practice deals with several hundred repeat prescriptions each week. Please allow 48 hours for us to process any request for repeat prescriptions. If you are requesting prescriptions to go to a designated pharmacy, please allow an extra working day.

We do not accept prescription requests over the telephone.

Home Visits during Surgery Hours

Home Visits are for patients who are too ill to come to the Practice. Please telephone before 11.00 am, unless a genuine emergency arises, so that the Doctors can organise their rounds. The GP does most routine visits after the morning surgery.

Change of Personal Details

It is important that we are told if you change your personal details and we would ask that you either come to the Surgery and complete a Change of Address/Name form or write to us.

Out of Hours Service

The Practice uses the ‘South East Health’ when it is closed. They may be contacted by telephoning 03000 242424.

Patients can also obtain advice by contacting NHS Direct on 0845 4647.

Expected Behaviour

It is our endeavour to offer the best medical service and care to patients at all times and that this should be done by our staff with compassion and politeness. We anticipate that our patients will reciprocate and treat our staff with consideration and politeness. Should any patient use abusive language or threatening behaviour towards any member of the Practice, we reserve the right to remove them from the Practice’s list forthwith.

Patients Signature: ______Date: ______

Please Print Name:______D.O.B:______