New patient summary form -individual Hillview Medical Centre

Please complete all sections of the form 1. Your details – please complete the boxes below

1.1 Name 1.2 Date of birth (write in capital letters)

1.3 Mobile 1.4 Home phone phone number number 1.5 Email address

1.6 Contacting you In the next few months, we are hoping to be able to start offering our patients the facility to be contacted by email and / or text. We also need to know if you are happy for us to leave messages for you on your answer phone if we need to get in touch with you. 1.6 (a) Are you happy for us to contact you by email? Yes / No (please circle) (internal use: add code 9NdS to patient record if ‘yes’) 1.6 (b) Are you happy for us to contact you by text? Yes / No (please circle) (internal use: add code 9NdP to patient record if ‘yes’) 1.6 (c) Are you happy for us to leave messages for you on your answer Yes / No phone? (please circle) (internal use: add code 9Ndi to patient record if ‘yes’) 1.7 First 1.8 Do you need Yes / No language an interpreter? 1.8 Allergies 1.9 Marital status

1.10 Are you 1.11 How often Regularly a Carer? Yes / No do you usually visit your GP Occasionally If yes – please surgery? write in who Very rarely for (please tick) 1.12 Would you like to help us to improve our services by joining our virtual patient participation group? Yes / No If you are happy for us to occasionally contact you by email about what you think of our services – please circle ‘yes’ in the box to the right.

2. Sharing your medical records with others The NHS would like to share your data with others in a number of ways. Please answer the questions below so that we know how you wish us to share your data. 2.1 Summary care records (www.nhscarerecords.nhs.uk)

Hillview Medical Practice is a part of the national Summary Care Record program. This enables each patient to have a summary of their key medical information held securely on the NHS central database, known as the NHS spine. The summary record can be used in an emergency if you needed treatment when access to the medical record held by your GP was not available; for example if you

______Saved in CQC under registration \ new patient registration pack – Sept 2014 Page 1 of 4 New patient summary form -individual Hillview Medical Centre call the doctor out of hours. You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please indicate below whether you would like to have your own Summary Care Record by indicating your decision below. A full explanation of each choice follows:

Options – please select one of these by ticking the box to the right of the Tick option one 1 I wish to have a Summary Care Record containing my medications allergies and adverse reactions or sensitivities to medications 2 I wish to have a Summary Care record with the above plus additional important medical information held on my record 3 I do not wish to have a Summary Care Record

(internal use only – add relevant option during patient registration process)

2.2 Care Data (www.nhs.uk/caredata)

Information about you and the care you receive is shared, in a secure system, by healthcare staff to support your treatment and care. It is important that the NHS can use this information to plan and improve services for all patients. The NHS would like to link information from all the different places where you receive care, such as your GP, hospital and community service, to help them understand the full picture. This will allow them to compare the care you received in one area against the care you received in another, so they can see what has worked best. Information such as your postcode and NHS number, but not your name, will be used to link your records in a secure system, so your identity is protected. Information which does not reveal your identity can then be used by others, such as researchers and those planning health services, to make sure we provide the best care possible for everyone. How your information is used and shared is controlled by law and strict rules are in place to protect your privacy.

Options – please select one of these by ticking the box to the right of the Tick option one 1 I do not want any of my personal confidential information held at my GP practice to be shared with anybody outside my GP practice 2 I do not want any personal confidential information about me that the NHS has gathered from any health and social care setting, to be shared with other organisations (internal use only – add relevant code to patient records: option 1: 9Nu0 / option 2: 9Nu4)

NB. Please be aware that there are times when, by law, we may have to release information about you (for example, if there is a public health emergency).

2.3 Sharing your records with other community health and social care teams

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We often work with other clinicians such as district nurses, community midwives, community matrons, health visitors, social services, palliative care. These teams are not employed by our practice but they may need access to your records to support you appropriately. They abide by all of our rules around patient confidentiality.

Are you happy for us to share your records with the community teams that we work with to provide your health support? (please circle) Yes / No

3. Your next of kin details – please complete the boxes below

3.1 Next of kin 3.2 Next of name kin telephone (please write in number capital letters)

3.3 Is your next 3.4 How is of kin male or Male / Female your next of female? kin related to (please circle) you?

4. Your ethnic background – please tick the appropriate box

White British Black African Bangladeshi Chinese

White Irish Black Caribbean Indian Any other ethnic background – please state:

White - any other Black - any other black Pakistani white background background

Any other Asian background

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Option 1 Option 2 Option 3 Option 4

I have never I used to smoke I am a current smoker I am a current smoker and smoked would like the number for the (please also write in (please also write in Stop Smoking Service - the date when you how many cigarettes 0845 602 3608 stopped) you smoke in a day)

(internal use – (internal use – code (internal use – code (internal use – code 8CAL) code 1371) 137S) 137R)

6. How much alcohol do you drink? - please circle the appropriate boxes

( Please note - the scores are Score 0 Score 1 Score 2 Score 3 Score 4 for internal use only) 5.1 How often do you have a drink that contains Never Monthly or 2 – 4 times 2 – 3 times 4 + times alcohol? less per month per week per week

5.2 How many standard alcoholic drinks do you have on a typical day when you 1 – 2 3 – 4 5 – 6 7 – 9 10 + are drinking?

5.3 How often do you have 6 or more standard drinks Never Less than Monthly Weekly Daily or on one occasion? monthly almost daily Signature Date

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