Please Use Black Ink and BLOCK CAPITALS

SPRINGWELL MEDICAL CENTRE

(Please use black ink and BLOCK CAPITALS)

NAME: / Date of Birth :
Home Number:
Work Number:
Mobile Number: / Single / Married / Divorced / Widowed / Other
What is your Occupation?
What is your Height?
What is your Weight?

FEMALE APPLICANTS (Aged 25-64) ONLY

CERVICAL CYTOLOGY CONFIRMATION

We are unable to register you at the practice until this section is completed. Please fill in only one section below:

a) I hereby confirm that I had a Cervical Smear performed:

Which country? ______

When? ______

The result was reported to me as normal / abnormal (please circle)

I was advised to have my next smear ______(please enter approx date)

b) I have never had a cervical smear but wish to be invited (Please tick if if appropriate)

Signed: Date:

If you DO NOT wish to have this important test performed please speak to reception.

Are you pregnant? Yes No

IF YES – Expected Due Date: ______or How many weeks pregnant: ______weeks

Do you have any allergies? If YES please list below: (drug and non drug related)

______

Are you on any regular Medication? If YES please note for your first prescription you will need to see the GP – please if possible bring your repeat prescription list from your previous GP

Do you receive your medication in a Dosette Box issued by the pharmacy? Yes No

If you answered yes to the above question, please give details of the pharmacy used.

Name of Pharmacy: ______

Address:

______

Telephone Number: ______

Do YOU have a history of any of the following medical conditions?

Condition / Tick if YES. / Approximate date of diagnosis
Heart Disease
Stroke
High Blood Pressure
Asthma
Diabetes
Chronic Obstructive Pulmonary Disease
Epilepsy
Hypothyroidism (Thyroid Deficiency)
Cancer
Mental Health Problems

Are you HOUSEBOUND? Yes No (please circle)

(Definition of housebound - unable to leave one's house, typically due to illness or old age)

Do you currently reside in supported accommodation? Yes No (please circle)

(Definition of Supported Accommodation - Supported housing can be described as any housing scheme where housing, support and sometimes care services are provided as an integrated package)

CARER

For medical purposes we need to know whether you are a carer for somebody else or you yourself have a carer. (Definition of a carer - A carer is someone who provides help and support to a partner, child, relative, friend or neighbour who could not manage without their help. This could be due to age, physical or mental illness, addiction or disability. (Please note this does not include normal parental care)

a) Are you a carer? Yes/No

b) Do you have carer Yes/No (please provide details – this is not mandatory)

Carers name: ______

Carers address: ______

Town/City: ______Postcode: ______

Phone Number(s): ______or ______

Signature of Patient: ______Date: ______

NEXT OF KIN

Please note that providing details of your next of kin DOES NOT give the named person any right to any part of your medical history. Your Medical Records are strictly private and confidential and no information will be disclosed to any other party without your written consent. (Definition of Next of Kin - your nearest relative, or somebody that you would want to contact in the case of an emergency)

Name: ______

Address: ______

Town/City: ______Postcode: ______

Phone Number(s): ______or ______

Relationship to Patient: ______

Signature of Patient: ______Date: ______

FAMILY HISTORY Have any of your family i.e. Father, Mother, Brothers or Sisters had:

Tick if Yes / Who was affected and age?
A heart attack below the age of 65 (woman) and 55 (men)
High Blood Pressure
Diabetes
High Cholesterol

The practice runs regular specialised clinics. If you have a family history of any of these conditions, please discuss with your doctor at your next appointment.

CHILD SURVEILLANCE

It is extremely important that we link all family members through the computer system. This does not affect your medical record but makes it easier for us to identify the parents and siblings of a child if we need to contact the parents/guardians for any reason.

If you live with a child or are registering a child please give us the details of anybody else living at the registered address.

Name ______DOB ______Relationship ______

CHILD IMMUNISATIONS

THIS IS AN ESSENTIAL REQUIREMENT TO ENABLE US TO REGISTER YOUR CHILD. This section MUST be completed for all children under the age of 7 years old.

If you have any documentation to back up the dates of any vaccinations please pass this to reception where we will take a photocopy and give you the original back. Please note that not all the vaccinations listed below will be given – this is a summary of all vaccinations depending on where your child was born/vaccinated.

DATE GIVEN / WHERE
1st DTP (Diphtheria, Tetanus, Pertusis)
2nd DTP (Diphtheria, Tetanus, Pertusis)
3rd DTP (Diphtheria, Tetanus, Pertusis)
1st Polio
2nd Polio
3rd Polio
Other Polio (if applicable)
1st Hib
2nd Hib
3rd Hib
Other Hib (if applicable)
DTP/POL/HIB – EXTRA DOSE (if applicable)
DTP/POL BOOSTER (between 3yrs4mths and 5yrs)
1st Rotavirus
2nd Rotavirus
1st MenC
2nd MenC
3rd MenC
1st PCV (pneumococcal)
2nd PCV (pneumococcal)
3rd PCV (pneumococcal)
OTHER PCV (if applicable)
Hib/MenC
MMR (Measels/Mumps/Rubella)
MMR Booster (Measels/Mumps/Rubella)
BCG
Varicella (chickenpox)
1st Hep A
2nd Hep A
3rd Hep A
1st Hep B
2nd Hep B
3rd Hep B
Reason for HEP B:
Oral Polio
Measels
Typhoid
OTHERS:

ETHNICITY/INTERPRETATION REQUIREMENTS

What is your ethnic group? Choose ONE section from A to E, then tick the appropriate box to indicate your ethnic group.

 Scottish  English  Welsh  Northern Irish

 British  Irish  Gypsy/Traveller  Polish

 ANY other White background

 Any mixed or multiple ethnic group

 Pakistani, Pakistani Scottish or Pakistani British

 Indian, Indian Scottish or Indian British

 Bangladeshi, Bangladeshi Scottish or Bangladeshi British

 Chinese, Chinese Scottish or Chinese British

 ANY other Asian background

 African, African Scottish or African British

 Caribbean, Caribbean Scottish or Caribbean British

 Black, Black Scottish or Black British

 Other Black background

 Arab

 ANY other ethnic group

 Ethnic group refused or not given

INTERPRETER NEEDS

Do you require an interpreter? YES / NO

If YES please tick the appropriate box to indicate which language you require:

 Akan  Albanian  Amharic  Arabic

 Bengali  Cantonese  Czech  Dutch

 Farsi  French  French Creole  Ganda

 German  Greek  Gujarati  Hakka

 Hausa  Hewbrew  Hindi  Igbo

 Japense  Korean  Kurdish  Lingala

 Lithuanian  Malayalam  Mandarin  Norwegian

 Pashto  Polish  Panjabi  Russian

 Serbian  Shona  Sinhala  Somali

 Spanish  Swahili  Swedish  Sylheti

 Tagalog  Tamil  Thai  Tigrinya

 Turkish  Ukranian  Urdu  Vietnamese

 Welsh  Yoruba  British Sign Language Makaton Sign Language

Please note in order for us to book an interpreter you need to specify this when booking your appointment. We usually require 3-5 days notice to arrange an interpreter as we use an outside agency. If you require to be seen urgently or with less notice you may be asked if you have a friend or relative who can interpret for you.

SMOKING

Do you currently smoke? Yes No

Have you ever smoked Yes No

The doctors advise all patients to stop smoking. The practice is happy to offer further advice and support including leaflets and referral to smoking cessation groups. Local pharmacies now provide Smoking Cessation advice and you can self refer to any walk in clinic. Please speak to reception for more information.

ALCOHOL

Please tick the statement which most closely describes your usual average alcohol intake (1 Unit = 1 glass wine, 1/2 pint of beer or a single measure of spirit

I never drink alcohol
I drink less than 1 unit per day
I drink between 1 and 2 units a day
I drink between 3 and 6 units per day
I drink between 7 and 9 units per day
I drink more than 9 units a day

EXERCISE

Healthy exercise involves activity that usually lasts for at least 20 minutes, raises your pulse and produces hard breathing. In younger people this might be running, cycling, aerobics or swimming or for older people this may be a brisk walk. How often do you take this type of exercise?

Daily
4 times weekly
Once weekly
Seldom
I cannot take exercise because of disability

FOR OFFICE USE ONLY:

Type of ID taken: ______

Type of passport: ______

Passport number: ______

Type of Visa: ______Expiry: ______

Back-up Visa Document: ______

Residency Document Submitted: ______

Checked By ______Date ______AM / PM

GPR and MQ entered by ______Date ______

NEW PATIENT REGISTRATION INFORMATION SHEET

To register with Springwell Medical Centre, all applicants MUST prove that they are currently residing in the UK regardless if they were born in the UK, registered with the NHS before, have a British passport etc. The documents provided must be in ENGLISH and prove you are residing in our catchment area. Please note this is not practice policy. These guidelines are set by the Scottish Government. If you fail to provide the documents we ask for we may not be able to register you for NHS treatment.

When submitting your application to register please ensure you bring in the ORIGINAL documents, we will simply check and return the original documents back to you. Documents submitted as proof of residency must be no older than 12 weeks.

Please note we only accept Registrations between 09.00 and 16:00 Tuesday to Friday (closed 12pm-1pm on a Thursday). We do not accept new registrations on Mondays. We can be extremely busy between 11:00 and 11:30 each day so please try to avoid submitting your forms then as you may be asked to take a seat until we have time to deal with your application.

Please read the categories below and bring in the relevant documentation:

BORN IN THE UK / UK CITIZEN

· Passport/Driving Licence/Birth Certificate AND

· One Proof of residency - Mortgage Papers/Tenancy Agreement/Utility Bill(s)/Council Tax/Proof of Benefits, Voters Roll etc. Please note we do not accept bank statements.

BORN OUTWITH THE UK BUT IN THE EU

TAKING UP RESIDENCY

· Passport or ID card AND

· One Proof of residency – Mortgage Paper/Tenancy Agreement/Utility Bill(s)/Council Tax/Proof of Benefits, Voters Roll, Shipping of goods Receipt etc. Please note we do not accept bank statements.

STUDENT

· Passport or ID card AND

· One Proof of residency - Mortgage Papers/Tenancy Agreement/Utility Bill(s)/Council Tax/Shipping of goods receipt/College letter with address on it etc. AND

· We will also ask for your European Health Insurance Card (EHIC) – if you do not have this you will be asked to get one. These are available online instantly.

DEPENDANT

· Passport or ID card AND

· Marriage Certificate/Birth Certificate (children)

Please Note: No proof of residency is required as long as spouse can provide all relevant residency documentation.

BORN OUTWITH THE EU

WORKER

· Passport and Visa (Visa must state working) AND

· A recent letter from your employer, or your work contract along with a current pay slip (no later than 4 weeks old) OR

· If you are self employed, invoices, letter from accountant, letter from HMRC stating you are registered, receipts of your work OR

· If you are an unpaid volunteer, a headed letter from the Organisation you work for that says what type of voluntary work you do.

· One proof of residency – Mortgage Papers/Tenancy Agreement/Utility Bill(s)/Council Tax, etc. Please note if your address is on the letter from your employer we can accept this as your proof of residency.

STUDENT

· Passport and Visa (Visa must state student) AND

· A recent letter from the College or University stating your course details, if its full or part time, start date and estimated end date. Please note we do not accept the College acceptance letter or college/university ID. You must be able to prove you are currently attending.

· One proof of residency – Mortgage Papers/Tenancy Agreement/Utility Bill(s)/Council Tax, etc. Please note if your address is on the letter from your College/Uni we can accept this as your proof of residency.

DEPENDANT

· Passport and Visa (Visa must state dependant) AND

· Marriage Certificate/Birth Certificate (children)

Please Note: No proof of residency is required as long as spouse can provide all relevant residency documentation.

TAKING UP RESIDENCY

· Passport and Visa (Visa must state “leave to remain” or “settlement”) AND

· One Proof of residency – Mortgage Paper/Tenancy Agreement/Utility Bill(s)/Council Tax/Shipping of goods Receipt/Proof of Benefits, Voters Roll etc. Please note we do not accept bank statements.

ASSYLUM SEEKERS / REFUGEES

· Documentation from the Home Office/UK Border Agency to say that you have refugee status or are seeking asylum.

PLEASE NOTE THAT NOT ALL REGISTRATION SCENARIOS ARE LISTED ABOVE.

This document is strictly a guideline – extra documents may be required depending on your situation.