Aylmer Lodge Cookley Partnership

AYLMER LODGE COOKLEY PARTNERSHIP

OPT OUT SIGNATURE SHEET

FOR SUMMARY CARE RECORD

ONLY FILL IN THE FORM IF YOU WANT TO OPT OUT

NAME: ……………………………………………………….

NHS NO: (IF KNOWN) ……………………………………………..

DATE OF BIRTH: ……………………………………………

I do not want a Summary Care Record created

Patient Signature ………………………………………

Date …………………………….

What is a Summary Care Record?

The Summary Care Record will contain basic information about any allergies you may have, unexpected reactions to medications and any prescriptions you have recently received. The intention is to help clinicians in Hospitals, Accident and Emergency Department and ‘Out of Hours’ health services to give you safe, timely and effective treatment.

Children under 16 years will have a Summary Care Record created for them unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please either make this information available to them or decide and act on their behalf.

You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you decide to proceed, but at any time in the future you, or a child you are responsible for, change you mind and choose not to have a Summary Care Record, all you need do is write to your Surgery informing them of your decision.

AYLMER LODGE COOKLEY PARTNERSHIP

HISTORY CARD

Please give as much information as you can

NAME : ………………………………… DOB : …………………..

ADDRESS : ……………………………………………………..

…………………………………………………………………….

TELEPHONE NO : ………………………………………………

MOB NO : ……………………………………………………….

EMAIL ADDRESS : ……………………………………………..

Have you had any serious disease, illnesses or operations? / Please list
Is there any hereditary disease in your family? / Please list
Are you allergic to any medication? / Please list
SMOKING STATUS / Smoker per day ( )
Ex-smoker ( )
Never smoked ( )
Are you taking any prescription medications?
If you have a repeat order form from your previous GP please attach it to this form / Please list
What is/was your job?
Exercise – do you take any regular form of exercise? / Please list
Next of kin
Relationship
Tel No
WOMEN ONLY
Have you had a Cervical Smear Test?
If so, when?
ALCOHOL CONSUMPTION
Please circle one for each question
QUESTIONS / 0 / 1 / 2 / 3 / 4
How often do you have 8(men)/6(women) or more drinks on one occasion? / never / LESS THAN MONTHLY / MONTHLY / WEEKLY / DAILY OR ALMOST DAILY
ONLY ANSWER THE QUESTIONS IF YOUR ANSWER ABOVE IS MONTHLY, WEEKLY OR DAILY
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
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
Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? / NEVER / LESS THAN MONTHLY / MONTHLY / WEEKLY / DAILY OR ALMOST DAILY

A REGULAR PINT OF BEER/LAGER/CIDER IS 2 UNITS

A BOTTLE OF WINE IS 9 UNITS, ALCOPOP OR CAN OF LAGER IS 1.5 UNITS

Are you a carer? / Y/N
If yes, please give details of who you care for: / Name:
Address:
Relationship to you:

YOU ARE ENTITLED TO MAKE AN APPOINTMENT FOR A HEALTH CHECK WITH A GP OR A NURSE. PLEASE ASK AT RECEPTION OR TELEPHONE 01562 822015 FOR AYLMER LODGE OR 01562 850770 FOR COOKLEY TO MAKE AN APPOINTMENT. PLEASE BRING A SAMPLE OF URINE WITH YOU TO THIS APPOINTMENT.

DO YOU HAVE ANY OTHER NEEDS THAT YOU FEEL THE DOCTORS NEED TO BE AWARE OF?

White Group / Other Groups / Mixed Group
British or mixed British / Chinese / White and Black Caribbean
English / Vietnamese / White and Black African
Scottish / Japanese / White and Asian
Welsh / Filipino / Black and Asian
Cornish / Malaysian / Black and Chinese
Northern Irish / Buddhist / Black and White
Ulster Scots / Hindu / Chinese and White
Other White Group / Jewish / Asian and Chinese
Cypriot (part not stated) / Muslim / Other Mixed, please specify, below:
Greek / Sikh
Greek Cypriot / Arab
Turkish / North African / Asian or Asian British Group
Turkish Cypriot / Middle Eastern / Indian or British Indian
Italian / (excluding Israeli, Iranian and Arab) / Pakistani or British Pakistani
Irish Traveller / Israeli / Bangladeshi or British Bangladeshi
Traveller Gypsy/Romany / Iranian / Punjabi
Polish / Kurdish / Kashmiri
Baltic States (Estonian, Latvian, or Lithuanian) / Moroccan / East African Asian
Russia and CIS / Latin American / Sri Lankan
French / South and Central American / Tamil
German / Mauritian, Seychellois, Maldivian, or St Helena. / Sinhalese
Spanish / Caribbean Asian
Albanian / Black or Black British Group / Mixed Asian
Bosnian / Black British / Other Asian, please specify, below:
Croatian / Caribbean
Serbian / African
Other republics from the former Yugoslavia / Somali
Other White, please specify below: / Other Black, please specify, below: / Is your ethnic category not on here? Please specify, below:

ETHNIC GROUP QUESTIONNAIRE

PLEASE TICK ONE OF THE FOLLOWING CATEGORIES BELOW