Wheatfield Surgery
60 Wheatfield Road
Luton
Bedfordshire
LU4 0TR
Tel 01582 601116
Fax 01582 666421
Dear New Patient
Welcome to Wheatfield Surgery
To register at our surgery the Department of Health requires that we will need to obtain documentation to prove that you are a permanent resident in the UK. Entitlement to NHS treatment is based on residency not citizenship. Anyone who can provide evidence that they have been legally resident in the UK will be entitled to register.
To register at the surgery we will need:
Step 1: Photographic Identification – passport, drivers licence etc
Step 2: Provide twoof the following up to date proof of address (within the last 3 months)
Council Tax Bill
Gas bill
Mortgage/rental agreement
Electricity bill
Bank statement
Step 3: NHS number from previous surgery WITHOUT THIS YOU WILL NOT BE REGISTERED
Step 4: Previous GP name and address (to obtain your medical notes)
Step 5: If you are on regular medication we will need previous medication slips or a summary print out from your previous GP stating which medication you are currently on.
REGISTRATION FORMS NEEDS TO BE FILLED OUT IN FULL WITH ALL DOCUMENTATION AT YOUR 1ST VISIT TO THE SURGERY.THEN TELEPHONE THE SURGERY AFTER 4 WORKING DAYS TO BOOK A NEW PATIENT SCREENING APPOINTMENT. YOUR REGISTRATION WILL NOT BE COMPLETED AND YOU WILL NOT BE ABLE TO SEE A CLINICIAN UNTILTHIS HAS BEEN APPROVED
This is a very busy Surgery .Failure to attend this appointment may result in your registration being declined.
Overseas Visitors
Ensure the following information is provided at your new registration screening.
Where have you been living for the past 12 months?
On what date did you return to the UK?
Which country did you come from?
What is the purpose of your visit to the UK?
Is it your intention to reside in the UK permanently? If ‘yes’ please state why
Can you prove you have the right to remain in the UK? (UK passport is insufficient evidence, as citizenship is irrelevant)
If you have answered yes to the above questions you must provide documentary evidence i.e. UK entry clearance visa, Home Office correspondence etc.
If these details are not provided we will not be able to continue with the registration. Unfortunately, if you require seeing a doctor or a nurse while your application is processed, you may be required to pay a charge for each appointment.
WE REQUEST THAT YOU COMPLETE THE NEW PATIENT INFORMATION FORM OVERLEAF IN FULL
NEW PATIENT INFORMATION FORM
Personal Information
Full Name: / Mr Mrs, Miss, Ms, DrADDRESS
Telephone number: / DATE OF BIRTH
Marital Status: / Occupation: / Gender: M / F
Next of Kin
Next of Kin Name:Relationship to patient:
Address of next of kin
Postcode
Telephone landline and mobile
Ethnic Origin
□ White British7007503664970000000□ White (other)7006309616900000000□ Indian □ Pakistani 7005747285000000000
□ White Irish7005691232000000000□ Mixed7005677117000000000 □ Black Caribbean 7005565876000000000□ Black African7005485277000000000
□ Bangladeshi7005283063000000000□ Chinese7005247403000000000 □ Other Asian 7005247644000000000□ Black (others)7004975850000000000
□ Other
Please state first spoken language:______
Past Medical History:
HAVE YOU SUFFERED FROM / YEAR OF DIAGNOSISDIABETES TYPE 1 / YES / NO
DIABETES TYPE 2 / YES / NO
ASTHMA / YES / NO
CHRONIC OBSTRUCTIVE PULMONARY DISEASE / YES /N O
HIGH BLOOD PRESSURE / YES / NO
STROKE / YES / NO
HEART ATTACK / ANGINA / YES / NO
HIGH CHOLESTEROL / YES / NO
ANY OTHER HEART PROBLEMS / YES / NO / YEAR OF DIAGNOSIS
GLAUCOMA / YES / NO
CANCER PLEASE SPECIFY / YES / NO
ANY OTHER MAJOR ILLNESS OR OPERATIONS / YES / NO
FAMILY HISTORY / RELATIONSHIP TO PATIENT
HEART DISEASE / YES / NO
GLAUCOMA / YES / NO
HIGH BLOOD PRESSURE / YES / NO
HIGH CHOLESTEROL / YES / NO
DIABETES / YES / NO
CANCER / YES / NO
PLEASE SPECIFY
ANY KNOWN ALLERGIES / YES / NO PLEASE SPECIFY
SMOKING STATUS
CURRENT SMOKER / YES HOW MANY PER DAY
EX SMOKER / DATE OR YEAR YOU STOPPED
NEVER SMOKED / YES / NO
CANNABIS / YES / NO
DO YOU DRINK ALCOHOL / YES / NO
HOW MANY UNITS OF ALCOHOL DO YOU DRINK PER DAY
HOW OFTEN HAVE YOU HADE 6 OR MORE UNITS IF FEMALE OR 8 UNITS IF MALE ON A SINGLE OCCASION IN THE PAST YEAR
DO YOU CARE FOR SOMEONE / YES / NO
CONTRACEPTION
WHAT CONTRACEPTION DO YOU USE
DATE OF LAST SMEAR IF FEMALE
ARE YOU CURRENTLY PREGNANT / YES / NO
Wheatfield Surgery
60 Wheatfield Road
Luton
Bedfordshire
LU4 0TR
Tel 01582 601116
Fax 01582 666421
Agreement principles between patient and ALL staff members
Please read the following principles and sign and return to the surgery when registering.
Wheatfield Surgery is a Zero Tolerance Policy practice and will NOT accept verbal abuse, threatening behaviour or intimidation
All patients are treated with respect and dignity and we ask the same in return
Patients arriving more than 10 minutes late for an appointment may be asked to re-arrange it
The doctor/nurse will see appropriate medical emergencies on the same day (on-call doctor for the day will see all emergencies)
Please do no bring anyone into the consultation room expecting the doctor to see them without an appointment
Should you present with multiple problems your doctor may ask you to make another appointment to discuss them
If you no longer need a previously booked appointment, please try and cancel at least 24 hours before the due date, appointments cancelled within less than one hours’ notice will not be cancelled.
Patients who do not attend 3 or more appointments with a doctor or nurse without prior cancellation may be removed from the list
There is no routine surgery at weekends
Please read the Practice Booklet
Any complaints or suggestions should be addressed to the Practice Manager
We operate a confidentiality policy, information will not be given to a third party without written consent
Rudeness and aggressive behaviour towards staff will not be tolerated; this may result in being removed from the patient list
I ______agree to the Wheatfield Surgery agreement principles.
Signature:______Date: ______
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
Thank you for your co-operation. Wheatfield Surgery Partners