Background Details

Contact Details

NHS Number Optional

If you do not have a NHS number what is the date you came to the UK?

Day Optional

Month Optional

Year Optional

Title

Prefix

Name

First Middle Last

Previous Surname (if applicable) Optional

Gender

Date of Birth

Day

Month

Year

Home Telephone Optional

Mobile Number

Do you content to be contacted via SMS?

Address

Street Address Address Line 2 City Post code

Previous Address

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

Enter Email Confirm Email

Do you consent to be contacted Via email?

Occupation Optional

Next of Kin

Do you have a next of kin?

(emergency contact person)

Name

First Last

Phone

Relationship to you

Previous GP

GP Name

Address

Street Address Address Line 2 City Post Code

Other Details

Country of Birth

Ethnicity

Religon Optional

Communication Needs

What is your main spoken language?

Do you need an interpretor?

Do you have any communication needs?

Do you have a learning disability?

Carer Details

Do you have a Carer?

Are you a Carer?

Medical History

Have you suffered from any of the following conditions?

Any other conditions, operations or hospital admission details: Optional

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

Relative Optional

i.e Parent, Sibling, Grandparent, Aunt/Uncle/Cousin etc

Medical Problem Optional

Allergies

Please record any allergies or sensitivities

Medication

Please check and include as much information about your current medication below.

Please give us your previous repeat medication list if possible, a medication review appointment may be needed: Optional

Name of your preferred pharmacy

Your Lifestyle

How many times a week do you exercise for more than 30 minutes?

Alcohol

Please answer the following questions which are validated as screening tools for alcohol use: AUDIT–C QUESTIONS Please check the correct boxes and check your score. (Scores can be found to the right of your answer)

How often do you have a drink containing Alcohol?

How many units of alcohol do you drink per week?

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?

A score of less than 5 indicates lower risk drinking

Scores of 5 or more require the following 7 questions to be completed:

Total Score:

4 or less

5 or more

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Total Score?

Smoking

Do you smoke?

How many cigarettes do you smoke a day?

How many cigarettes did you smoke a day?

How old were you when you started smoking?

How old were you when you stopped smoking?

Would you like help to quit smoking?

For further information, please see:
www.nhs.uk/smokefree

Height and Weight

Height

Weight

Women's Health

Are you Female?

Do you use any contraception?

Are you currently pregnant or think you may be?

Expected due date

Day

Month

Year

Students

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression.
For further information, please see:
www.nhs.uk/Livewell/Studenthealth

Are you a student?

I am less than 24 years old and have had two doses of the MMR Vaccination

I am less than 25 years old and have had a Meningitis C Vaccination

Electronic Prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional

PPG – Patient Participation Group

Would you like to be involved in our Patient Participation Group?

Blood and Organ Donation

For more information on organ donation please visit: www.organdonation.nhs.uk

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

I confirm that the information I have provided is true to the best of my knowledge.

Name

Date

Day

Month

Year

Your Health Record

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

I wish to give EXPRESS CONSENT for medication, allergies and adverse reactions only to be included in my Summary Care Record

I wish to give EXPRESS CONSENT for medication, allergies, adverse reaction and additional information to be included in the my Summary Care Record

I DO NOT CONSENT to have my Summary Care Record and do not wish to have one

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

Yes (recommended option)

Your Summary Care Record (SCR)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

Yes (recommended option) Optional

No Optional

I wish to have online access to:

Please tick all that apply

View & book appointments

View & request medication

Access my coded medical record (contains any medical codes that have been recorded)

Access my full medical record (contains medical codes and any free text that has been recorded)

Access my Summary Care Record

Complete online questionnaires

I wish to access my medical record and understand and agree with each statement:

Please tick all that apply

I have read and understood the ‘Important Information’ section below

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Access to GP Online Services

Important Information – Please read before completing form below

If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal.

The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.

Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

For further information, please see:
www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx

Date Optional

MM slash DD slash YYYY

Untitled Optional

Number Optional