Have You Been Registered with Us Before? YES NO

HIGHCLIFFE MEDICAL CENTRE

NEW PATIENT QUESTIONNAIRE

Have you been registered with us before? YES  NO 

Title
Full Name
Any previous name
Date of Birth
Address
Postcode
Town and Country of birth
Home telephone No
Mobile No
email address
Marital status
NHS number
Previous address in UK
Name of previous Doctor
Address of previous Doctor
If from abroad date you first came to the UK

We can send you appointment reminders and other information to your mobile number/email do you consent to this  (please tick box)

Do you have any special communication needs? /  Yes /  No
Are you deaf /  Yes /  No
Are you blind /  Yes /  No
Do you use British sign language /  Yes /  No
Do you use Makaton sign language /  Yes /  No
Do you lip read /  Yes /  No
Do you use a note taker /  Yes /  No
Do you use telecommunications device for the deaf /  Yes /  No
Do you use a legal Advocate /  Yes /  No
Do you use a Citizen Advocate /  Yes /  No

What is your preferred method of communication?

Letter  email  home telephone  mobile number 

Braille  Grade 1  Grade 2 

Written – Font 12  Font 24  Font 28 

Ethnic origin

Please indicate your ethnic origin:

 British or mixed British  Irish  African  Caribbean  Indian  Pakistani

 Bangladeshi  Chinese  Other (please state):

 Decline to state

Next of Kin details

Next of kin
Relationship
Their telephone No
Their mobile No
Their address
Are you a carer for someone YES  NO 
Their name
Their address
Does somebody care for you YES  NO 
Carers Name
Carers address
Carers tel No

If you have answered YES to the carers, please ensure that you let us know if this situation changes – thank you.

About your Health

Do you have any of the following conditions?

(If yes an appointment will be made for you to see one of our clinical team).

Please tick / Diagnosis date / Please tick / Diagnosis date
Asthma / Heart Disease
COPD / Cancer
Diabetes / High Blood pressure

Please give details and dates of any other serious illnesses or operations

Illness/Operation / Date

Are you under the care of a specialist: YES NO

Specialist Name/s / Condition

If you need to transfer your care to a local specialist please arrange a telephone consultation with one of the GPs.

Do you have a family history of any of the following conditions:

Asthma / Heart Disease i.e. heart attack
Diabetes / DVT
Cancer / Stroke

About your medication

Are you taking any regular medications? YES  NO 

(If yes an appointment will be made for you to see one of our clinical team).

Please list below or attach your repeat prescription list. We do require evidenceof your prescription i.e. repeat prescriptions list. We will not be able to issue any medication before this is received.

Medication / Dose / How often / Reason

Do you have any allergies to any medications?

Allergies to medications:

Your Smoking Status (Please tick)

Never Smoked
Ex-Smoker / Date you gave it up
Current smoker / How much do you smoke

If you are currently smoking we can help you to stop?

We run smoke stop sessions here at the surgery would you like help to

Stop smoking? YES  NO 

Alcohol screening tool

This is one unit of alcohol…

…and each of these is more than one unit

AUDIT – C

Questions / Scoring system / Your score
0 / 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

Score

Please answer the following remaining questions

Questions / Scoring system / Your score
0 / 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, Score

16 – 19 Higher risk, 20+ Possible dependence

TOTAL Score equals

AUDIT C Score (above) +

Score of remaining questions

NHS organ donation

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

 Any of my organs and tissue or

 Kidneys Heart  Liver  Corneas  Lungs  Pancreas  Any part of my body

Online services for patients

We currently offer a range of online services, currently these are: the ordering of prescriptions, the ability to book face to face appointments, a summary view of your current medications sensitivities and allergies and a view of your detailed code record. Other facilities will become available during 2016/2017.

I wish to apply for the login and password information to enable me to access the online services available from the practice: YES  NO 

Data Sharing

Please complete the information below with your choices on sharing your data and hand to Reception with your registration forms.

Name
Date of birth
Address

Carer

Are you happy for us to contact your carer about you? (If you have One)

I agree to you contacting my carer about me ☐

I do not agree about you contacting my carer about me ☐

SystmOne – Practice computer system for recording your clinical data

I agree to information about me being shared with ☐

other services using Systmone medical systems

I do not agree to information about me being shared with ☐

other services using Systmone medical systems

I agree to the practice seeing information recorded at ☐

other services using Systmone systems.

I do not agree to the practice seeing information recorded ☐

at other services using Systmone systems.

Health Vaccination Programmes i.e. flu, shingles

I agree to being invited for vaccination programmes by the data processor ☐

I do not agree to being invited for vaccination programmes by the data ☐

processor.

Summary care Record

I do not wish to have a Summary care Record ☐

(N.B. this will mean NHS Healthcare staff caring for you may not be aware of your current medications, any allergies or reactions to previous medication.)

Data for research

I do not wish identifiable data about me to leave the practice ☐

I do not wish data about me to be shared by HSCIC ☐

I accept the responsibility to advise the medical Centre of any changes to my contact details.

Please sign below

Signature of patient:______

On behalf of patient:______

Date: ______/______/______

Please return all 6 forms to reception with proof of any medications you take as we will not be able to issue a prescription to you without it.

As a new patient you are invited for a new patient health check, if you wish to have this check please ring 01425 283246 to make an appointment.