Henfield Medical Centre
PRIVATE & CONFIDENTIAL
Dr Karen Crawford ClarkeDr Patrick Reade
Dr John Derrett
Dr Cheryl Lambe
Dr Olivia Snape
Dr Camilla Drew
Dr Gordana Ninkovic-Chapman
Katie Hill, Managing Partner
Henfield Medical Centre
Deer Park
Henfield
West Sussex
BN5 9JQ
Tel: 01273 492255
Fax: 01273 495050
TO HELP OUR SURGERY OBTAIN IMPORTANT BASIC MEDICAL INFORMATION WHICH WILL ALLOW US TO PRACTICE BETTER MEDICINE, PLEASE FILL IN THIS FORM AS FULLY AS POSSIBLE. THIS INFORMATION WILL REMAIN CONFIDENTIAL.
GENERAL INFORMATION:
TODAY’S DATE______DOB______SEX:______MARITAL STATUS______
FULL NAME______
ADDRESS______
______POSTCODE______
TELEPHONE NO (HOME)______TELEPHONE NO (WORK)______
MOBILE NUMBER______
I CONSENT TO THE SURGERY USING MY MOBILE NUMBER TO SEND ME TEXTS ______
EMAIL ADDRESS:______
I CONSENT TO THE SURGERY USING MY EMAIL ADDRESS TO SEND ME EMAILS______
IF REGISTERING A CHILD, PLEASE GIVE THE NAME OF THE SCHOOL THEY ATTEND______
NEXT OF KIN______RELATIONSHIP______
Next of kin contact details______
ETHNIC ORIGIN (Please circle as appropriate)
WHITE BRITISH1 IRISH2 OTHER WHITE3
BLACK OR BLACK BRITISH AFRICA4 CARIBBEAN5 OTHER BLACK6
ASIAN OR ASIAN BRITISH BANGLADESHI7 INDIA8 PAKISTANI9
MIXED PARENTAGE WHITE & BLACK CARIBBEAN10 WHITE & BLACK AFRICAN11
WHITE & ASIAN12 OTHER MIXED 13 PREFER NOT TO SAY 16
CHINESE14 OTHER ETHNIC GROUP 15
MEDICATION : ARE YOU ON ANY REGULAR MEDICATION AT PRESENT?
If yes, please provide written evidence by way of a repeat prescription sheet or a print out from your previous surgery
DO YOU CONSENT TO HENFIELD MEDICAL CENTRE OBTAINING YOUR MEDICAL RECORDS ELECTRONICALLY FROM YOU PREVIOUS SURGERY? CONSENT / DISSENT
DO YOU HAVE ANY ONGOING MEDICAL PROBLEMS
if yes, Please give brief details......
…………………………………………………………………………………………………………………………………….
DO YOU HAVE ANY KNOWN ALLERGIES? YES / NO;
if YES, please give details: ………………………………………………………………………………………………..
HEIGHT………………………………. WEIGHT………………..………..
SMOKING STATUS: A) NEVER SMOKED B) EX-SMOKER C) CURRENT SMOKER (PLEASE CIRCLE AS APPROPRIATE)
ALCOHOL: APPROX HOW MANY UNITS OF ALCOHOL DO YOU DRINK PER WEEK: ……………..……………
ALCOHOL: F.A.S.T
QUESTIONS / SCORING SYSTEM0 1 2 3 4 Your Score
How often do your have 8 (men) 6 (women) or more drinks on one occasion / Never / Less Than Monthly / Monthly / Weekly / Daily or almost daily
Only answer the following questions if your answer is monthly or more…..
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 because of drinking? / Never / Less Than Monthly / Monthly / Weekly / Daily or almost daily
Has relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? / No / Yes. But not in the last year. / Yes,during the last year.
FAMILY HISTORY
HAVE ANY CLOSE RELATIVES SUFFERED FROM ANY OF THE FOLLOWING DISEASES?
AT WHAT AGE DID THEY BEGIN? E.G. DIABETES – FATHER AGED 48.
HEART ATTACK______STROKE______
HIGH BLOOD PRESSURE______DIABETES______
THYROID DISEASE______GLAUCOMA______
BREAST CANCER______OVARIAN CANCER______
BOWEL CANCER______PROSTATE CANCER______
MEDICATION
IF YOUR RESIDENCE IS MORE THAN ONE MILE AWAY FROM A CHEMIST, WE ARE ABLE TO OFFER YOU OUR DISPENSING SERVICE DIRECT FROM THE MEDICAL CENTRE.
IF YOU DO NOT WISH TO AVAIL YOURSELF OF THIS SERVICE,
PLEASE TICK your preference
COLLECT YOUR PRESCRIPTION FROM THE MEDICAL CENTRE AND TAKE TO A CHEMIST OF YOUR CHOICE □
SEND IN A SAE FOR THE PRESCRIPTION TO BE SENT TO YOU □
SEND PRESCRIPTION TO LLOYDS. □
PLEASE RETURN THE COMPLETED FORM TO HENFIELD MEDICAL CENTRE AS SOON AS POSSIBLE ALONG WITH THE PURPLE REGISTRATION FORM
FOR ADMINSTRATION PURPOSES: ensure that both the dispensing box is ticked and the correct location is allocated.
Having Your Say!
Henfield Medical Centre is encouraging patients to give their views about the services we provide. We would like to be able to ask the opinions of as many patients as possible
Would you like to have a say? We would like to hear your views.
By providing your email details we can add them to a contact list which means we may contact you now and then to ask a question or two about our services.
Please complete below if you would be happy to help us in this way and hand the slip to a receptionist.
Many thanks
Email: (PRINT PLEASE)______Name:______
Signature______
1. Common patient questions and answers
Q. Why are you asking people for their contact details?
A. We would like to be able to contact people occasionally to ask them questions about the surgery and how well we are doing to identify areas for improvement.
Q. Will my doctor see this information?
A. This information is purely to contact patients to ask them questions about the surgery, how well we are doing and ensure changes that are being made are patient focused. If your doctor is responsible for making some of the changes in the surgery they might see general feedback from patients.
Q. Will the questions you ask me be medical or personal?
A. We will only ask general questions about the practice, such as short questionnaires.
Q. Who else will be able to access my contact details?
A. Your contact details will be kept safely and securely and will only be used for this purpose and will not be shared with anyone else.
Q. Do I have to leave my contact details now?
A. No, but if you change your mind, please let us know.
Q. What if I no longer wish to be on the contact list or I leave the surgery?
A. We will ask you to let us know by e-mail or letter if you do not wish to receive further messages.
XaRFi – Consent to Email Correspondence Date XaZGu – Declined Consent to Email Correspondence Date
XaQid – Consent to Text Date XaQmZ – Declined Consent to Texts Date
XaXbY - Consent for SCR Upload Date XaXj6 – Dissent for SCR Upload Date