NEW PATIENT QUESTIONNAIRE

PERSONAL DETAILS
Title / Miss//Mr/Mrs/Ms/Other: ...... / Have you been registered here before? / Yes No
Surname / Previous Name
Forename(s) / Date of Birth
NHS No / Gender / Male Female
Marital Status / Single Married Separated Divorced Widowed Cohabitating
ETHNICITY – How would you describe your ethnicity?
White / British (9i00) / Irish (9i1) / Other White (9i2)
Mixed / White & Black Caribbean (9i3) / White & Black African (9i4) / White & Asian (9i5) / Any other mixed background (9iFK)
Asian / Bangladeshi (9i9) / Indian (9i7) / Pakistani (9i8) / Any Other Asian background (9iA)
Black / Caribbean (9iB) / African (9iC) / Any Other Black background (9iD)
Other / Chinese (9iE) / Travellers (9i2D) / Any Other Ethnicity (9iF) / Do Not Wish to State (9iG)
LANGUAGE
Written / Spoken / Written / Spoken / Written / Spoken
Arabic / 13n0 / 13l0 / Hindi / 13nD / 13l8 / Sylheti / 13lJ
Bengali / 13n8 / 13l1 / Punjabi / 13n2 / 13lE / British Sign Language / 13ZM
Chinese/Cantonese / 13n9 / 13l2 / Urdu / 13n7 / Do Not Wish to State / 13ZG
English / 13nB / 13l4 / Mirpuri / 13b4
Gujerati / 13Z62 and write in / 13l6 / Pashtu / 13Z64
CONTACT DETAILS
Address / Home Tel No
Mobile No
Work No
Postcode / Email Address
Occupation
Online Services: Kingswinford Medical Practice offers Internet facilities for booking GP appointments and ordering repeat medication online. You need to be registered in order to access this service. You can only apply for yourself and must be aged 16 and over. If under the age of 16, then parental consent must be obtained.
Do you want to be registered for the online services? / Yes No / If yes, please ask a member of reception for the appropriate registration form.
Declaration: Please supply me with my User Name and Password details to allow me to access the online appointment booking and repeat medication ordering services. I understand that I am responsible for securing these details to prevent unauthorised persons from accessing my record on line. In the event that my security details have been compromised I will inform the Practice immediately so that access can be blocked and a new password issued. If at any time I wish to permanently cease Internet access I will inform the practice in writing. I confirm that I have read the terms and conditions and agree to them. **
OFFICE USE ONLY
Proof of Identity / Passport / Identity Card / Photo Driving Licence / Other
Proof of Address / Utility Bill / Bank Statement / Tenancy Agreement / Other
Other (Proof of Identity and Address) / Seen by Reception / Yes No
Name and signature of staff member / Date
NEXT OF KIN
Relationship to Patient / Name
Date of Birth / Address
Emergency Contact
In the event of an emergency, if an appointment needs to be re-scheduled / cancelled or the surgery needs to discuss your record please confirm whether you would like the above named person to act on your behalf / Yes No
I ...... consent to allowing ...... to act on my behalf should the practice be unable to contact me.
Signature / Date
CARER INFORMATION
Are you a Carer? / Yes No / Is someone a Carer for you? / Yes No
What is your relationship with the Carer / Name
Date of Birth / Address
Emergency Contact
HEALTH DETAILS
Do you consider yourself to have a disability? / Yes (13VC) No / Are you Registered Disabled? / Yes (13VC5) No
Please provide details of impairment / Physical Impairment / Learning Disability/Difficulty
Sensory Impairment / Mental Health Condition
Other (please state)
Repeat Medication
Are you on any repeat medication? / Yes No
If “Yes”, please hand in your repeat prescription slip to Reception.
If “yes”, Do you understand why you are taking your current medication? / Yes No
Do you take your medicine(s) regularly, as prescribed by your Doctor / Yes No
Are you experiencing any side effects from your medication? / Yes No
If “yes”, please describe as fully as possible
Do you regularly take any medication that is not prescribed by your GP? (e.g. bought from pharmacy, supermarket etc) / Yes No
If “yes”, please state
PHYSICAL ACTIVITY
Please describe your physical activity: / Exercise physically impossible / Avoid even trivial exercise
Enjoy light exercise / Enjoy moderate exercise / Enjoy heavy exercise
If appropriate would you be interested in an exercise assessment? / Yes No
MEDICAL HISTORY
Do you have, or have you had, any serious health problems (including operations) / long term conditions?
Please tick the boxes where applicable and provide details if you can
Details / Date (if known)
Asthma
Cancer
COPD
Chronic Kidney Disease
Diabetes
Epilepsy
Heart Attack/Disease
High Blood Pressure
High Cholesterol
Stroke
Mental Health Problems
Underactive Thyroid
Circulation Problems
Other Serious Illnesses
Any Operations
Any Known Allergies / Yes No / Allergic To
Details of the reaction
Self-Management programme – Are you aware that there are courses available locally to help manage your health better? Would you like to receive more information? / Yes No
FAMILY MEDICAL HISTORY
Have any of your immediate relatives (brothers/sisters/parents) had any of the following:
Please tick the boxes where applicable and give details if you can
Details / Relationship / Date (if known)
Asthma
Cancer
Diabetes
Heart attack or angina before age 60
Heart attack or angina over age 60
Stroke
Any Inherited Diseases
HOSPITAL CARE
Are you currently under hospital care? / Yes No / If ‘Yes’, then complete details below
Hospital Name / Name of Consultant / Nature of Problem
FEMALES ONLY
Date of last cervical smear? / Are you pregnant? / Yes No
Have you had a hysterectomy? / Yes No
Contraception – what is your current method of family planning?
None / Coil / Depo Provera Injection
Contraceptive Pill / Sterilisation / Implant
Condom / Partner had Vasectomy / Hysterectomy
IMMUNISATIONS / VACCINATIONS
Please provide details of all vaccinations / Date / Date
Diptheria/Tetanus/Whooping Cough/Polio / 1 / Meningitis C / 1
2 / 2
3 / 3
Pneumococcal / 1 / Hib / 1
2 / 2
3 / 3
Measles/Mumps/Rubella (MMR) / 1 / Hib Booster
2 / Men C Booster
Pre-school Diptheria / Tetanus / Whooping Cough / Polio / HPV / 1
Rubella / 2
BCG / 3
Teenage Booster Diptheria / Tetanus / Polio / Other
Other / Other
HEALTH DETAILS CONTINUED - ADULTS / OVER 18’s
Alcohol – Alcohol use can affect your health and can interfere with certain medications and treatments.
Your answers will remain confidential so please be honest. **Use the guide below to decide how many units you drink a week.
Do you drink any alcohol? / Yes No
How often do you have a drink? / Never (0) / Monthly or Less (1) / 2-4 times per month (2)
2-3 times per week (3) / 4 or more times per week (4)
How many units of alcohol do you drink on a typical day when you are drinking?
1-2 (0) / 3-4 (1) / 5-6 (2) / 7-8 (3) / 10+ (4)
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 (0) / Less than monthly (1) / Monthly (2) / Weekly (3) / Daily or almost daily (4)
Scoring: A total of 5+ indicates increasing or high risk drinking. An overall total score of 5 or above is AUDIT-C positive
Drugs –Drug use can affect your health and can interfere with certain medications and treatments.
Your answers will remain confidential so please be honest.
Do you or have you used drugs? / Yes No / Do you have a drug addiction? / Yes No
Smoking
Are you a smoker? / Yes No / What do you smoke? Cigarettes Pipe Cigar
How many do you smoke per day?
Are you thinking about stopping smoking? / Yes No
Are you ready to stop smoking / Yes No
Ex-Smoker? / Yes No / When did you stop smoking?
Never Smoked? / Yes No
DEPRESSION SCORE
Over the past 2 weeks, how often have you been bothered by any of the following problems?
  1. Little interest or pleasure in doing things

Not at all / Several days / More than half the days / Nearly every day
  1. Feeling down, depressed or hopeless

Not at all / Several days / More than half the days / Nearly every day
COMMENTS
Do you have any comments in respect of your medication of your health? If yes, please state
______
______
______
______
______
SUMMARY CARE RECORD
The NHS in England has introduced the Summary Care Record, which will be used in emergency care.
The record will contain information about any medicines you are taking, allergies you suffer from andany bad reactions to medicines you have had to ensure those caring for you have enough informationto treat you safely.
Your Summary Care Record will be available to authorised healthcare staff providing your care anywherein England, but they will ask your permission before they look at it. This means thatif you have an accident or become ill, healthcare staff treating you will have immediate access to importantinformation about your health.
Kingswinford Medical Practice is supporting Summary Care Records and as a patient you have a choice:
Yes I would like a Summary Care Record (9Ndl) – you do not need to do anything and aSummaryCare Record will be created for you
No I do not want a Summary Care Record (9Ndo)– Please ask at Reception for a Summary Care Record ‘Opt Out Form’. This form will need to be completedand handed to a member of the Reception staff

TERMS AND CONDITIONS

*) SMS Messaging Service

By signing this agreement you are consenting for Kingswinford Medical Practice to contact you via SMS message for the following reasons:

  • To confirm booked appointments at the Surgery
  • To remind you of an appointment the day before
  • To inform you of any important information regarding Kingswinford Medical Practice, i.e. any campaigns or changes to services.

Text messages will never contain any information that can identify you personally or any clinical information.

As part of the registration process you will be required to show to a member of our reception staff a photo ID, (passport or photo driving licence) in order to confirm your identity.

You can only apply for yourself and you must be 16 or over to register for this service.

You are responsible for informing the Surgery of your correct mobile telephone number and you will notify the Surgery should this number change. Kingswinford Medical Practice cannot be held responsible for messages sent to this number in case you fail to inform us of any relevant changes. Kingswinford Medical Practice reserves the right to terminate this service (or part of it) without any notice.

**) Online Services

Patient Access (previously EMIS Access) is an online system which is a secure facility for accessing part of your medical records online.

Our patients may use this Internet access facility to request their repeat prescriptions and book appointments online. You can only apply for yourself and you must be 16 or over to register for this service. If under the age of 16, then parental consent must be obtained and a parent/guardian can access the account on their child’s behalf.

When a child turns 16, then the online account will be discontinued as thereafter parental access is no longer allowed.

All details entered online are secure. Furthermore, our Practice has a strict confidentiality policy.

REGISTRATION PROCEDURE

As part of the Registration procedure you will be required to show to a staff member of our reception a photo ID (passport or photo driving licence) in order to confirm your identity.

It is a further requirement that you sign the declaration on the first page of the New Patient Questionnaire.

Your repeat prescriptions may be ordered online after you have registered for the Patient Access service. Once you are logged into the system, you will be able to request your repeat prescriptions using this system. You will see your list of repeat medications and can tick the ones you require to order. You will also be able to book a GP appointment.

If you have forgotten your password, then you will need to come into the Surgery and request one of the receptionists to reset your account. It is not possible to search our system for your password due to security reasons. Your password is only known to you.

As part of the agreement and in the interest of the security of our system it is important that you keep your Password and User Name safe and secure. You agree that you will not disclose any of the security codes or password to any third party. It should not be necessary to reveal your password to our Staff.

We are constantly monitoring the use of the Internet access service. Breach of the Terms and Conditions or any inappropriate use of this service will lead to review of your access and may subsequently be revoked.

Kingswinford Medical Practice reserves the right to terminate this service (or part of it) without any notice.

It may be necessary to amend the Terms and Conditions in future. Any of such changes will be displayedon our website and on the Surgery notice boar