The Surgery New Patient Health Questionnaire
Total Page：16
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THE SURGERY Dr Zaw Thike MBBS DFFP MRCGP DRCOG Dr Julie Marshall MBCHB DFFP DRCOG PRIVATE AND CONFIDENTIAL NEW PATIENT REGISTRATION QUESTIONNAIRE To be completed for patients over 16 THE SURGERY CHURCH ROAD LYMINGE FOLKESTONE CT18 8HY Telephone: 01303 862109 Fax: 01303 863643 _________ BRANCH SURGERY 99 CANTERBURY ROAD HAWKINGE KENT CT18 7BS Telephone: 01303 893381 Fax: 01303 893381 Email: [email protected] ____________________________________ A very warm welcome to our small rural dispensing Surgery which accepts patients from Lyminge, Hawkinge, Elham, Stelling Minnis, Rhodes Minnis, Ottinge, Postling, Newington and other local surrounding Villages. Please kindly complete all 4 pages of this questionnaire along with the fully completed GMS1 registration form so we can input your information onto our clinical system. Please refer to the surgery booklet in relation to information within the questionnaire as well as other relevant information you may find useful. Please note that we offer appointments at both Lyminge and Hawkinge, and you may be required to travel to either site for an appointment. Your Allocated Named GP is Dr Zaw Thike Should you require any further information or assistance then please do not hesitate in speaking to a member of the reception team or the Practice Manager PLEASE BRING BACK TO THE SURGERY – DO NOT POST Reception Only – Please initial to confirm coded Contact Details Allergies Smoking Status Consent Summary Care GP Data Extraction Carer Next of Kin Allocated GP codes New Patient Check Communication/informati on 67DJ appointment date needs 9NN60 Emis Number Updated August 2016 Page 1 of 4 PRIVATE AND CONFIDENTIAL Personal Information Title: Forename: Surname: Occupation: Date of Birth: NHS Number: Address: Postcode: Telephone Number: Mobile Number: Email Address: Ethnicity First Language Do you have any communication/information needs relating to a disability, impairment or sensory loss and if so what are they (please give details) ___________________________________________________________ ____________________________________________________________________________________________ Do you have any allergies? YES NO If yes please state what they are: Do you suffer from any of the following illnesses? - Please detail date diagnosed Angina Asthma Atrial Fibrillation COPD Depression Diabetes Dyspepsia (Indigestion) Epilepsy High Blood Pressure Heart Failure Stroke Thyroid Disease Myocardial Infarction (Heart Chronic Heart Disease Chronic Kidney Disease Attack) Any other illnesses (please give details) ______________________________________________ Family History Have any family members (mother, father, uncle, aunt, grandparents, nieces, nephews, brothers, sisters) ever suffered from any serious illness? (Diabetes, Heart Disease, High Blood Pressure, Glaucoma) Relationship (e.g. Mother) Date of Birth Detail Illness Smoking Status (please circle answer) Current Smoker Ex Smoker Never Smoked Drinking Habits (Please circle answers) 1 Drink = ½ pint beer or 1 glass of wine or single spirit How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a 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+ Men: How often do you have EIGHT or more drinks on one occasion? Women: How often do you have SIX or more drinks on one occasion? Never Less than Monthly Monthly Weekly Daily or almost daily If you would like to discuss your alcohol intake then please make an appointment with the Practice Nurse Page 2 of 4 Are you under the care of a Hospital Specialist YES NO If yes, please give details: Women Only If you are using contraception at present then please give method? When did you have your last smear? Have you had a hysterectomy? YES NO Have you had a mammogram? YES NO Consent Prescription YES NO I give consent for prescriptions to be collected on my behalf Messages YES NO I give consent for the practice to leave messages on my answerphone Messages with 3rd Party YES NO I give consent for the practice to leave a message with the persons named below about any aspect of my medical treatment Names: _____________________________________________________________________________ _____________________________________________________________________________ Medical Details YES NO I give consent for the practice to disclose results and to discuss any medical treatment or problems with the persons named below: Names: _____________________________________________________________________________ _____________________________________________________________________________ Any consent given will remain in force until further notice or cancellation by me Patient signature: Date: STAFF ONLY – Added to Emis System Name: Date: Summary Care Record On registering at the surgery patients are automatically given an electronic summary care record. Staff will be permitted to access information, via strict security measures, if they are involved in your treatment. Having a summary care record will help ensure that the right people have the right information at the right time. For example current medication, allergies etc…) Should you choose not to have a summary care record please complete details below: I do not wish to have a summary care record Patient Signature For children under 16 years agreement will be assumed unless the parent or guardian opts out on their behalf. GP Data Extraction Service Confidential information from your medical records can be used by the NHS to improve the services offered so that the best possible care can be provided for everyone. This information along with your postcode and NHS Number but not your name is sent to a secure system to be linked with other NHS services. I do not wish to participate in GP data extraction Patient Signature For children under 16 years agreement will be assumed unless the parent or guardian opts out on their behalf. For more information please visit NHS choices website www.nhs.uk Page 3 of 4 Next of Kin Name__________________________________________________________________________________ Contact Number ________________________________________________________________________ Relationship to patient___________________________________________________________________ Is this your emergency contact? YES / NO STAFF ONLY – Added to Emis System Name: Date: Carer What is meant by a carer? A carer is someone wo looks after a relative or friend who needs support because of age, physical or learning disability or illness. Parent carer - a parent of a disabled child often see themselves as parents rather than carers, however additional services and support may be available Young carers – This means carers who are under 18. The person receiving care is often a parent, but it could be a brother, sister, grandparent or another relative who needs support. If you are a carer and would like your name to be added to our register of carers, then please complete the following information: Are you a Carer? YES NO Name of person being cared for______________________________________________________________ Type of disability_________________________________________________________________________ Telephone Number _______________________________________________________________________ Relationship to carer ______________________________________________________________________ As the person being cared for we need permission to put your name on the carer register. This information is confidential. Signature _____________________________________________ Date _____________________________ If the person being cared for is unable to provide a signature then please indicate reason ________________ Does someone care for you? YES NO Name of carer ___________________________________________________________________________ Telephone Number _______________________________________________________________________ Relationship to you _______________________________________________________________________ Patient Participation Group Would you like to receive information about our patient participation group via email? YES NO If yes please ensure you have given your email contact above. New patient questionnaire – 4 page document read and completed Patient Signature Date completed Thank you for your time in completing this questionnaire which will help us until we receive your medical records from your previous GP. Page 4 of 4 .