To Register with GPS Healthcare Please Complete the Following Actions;

GPS Healthcare New Patient Registration Welcome to GPS Healthcare To Register with GPS Healthcare please complete the following actions;

Please hand this information to the Reception Desk and complete the following steps;

PLEASE ENSURE YOU COMPLETE ALL OF THE STEPS OUTLINED ABOVE IN ORDER THAT YOUR REGISTRATION APPLICATION CAN BE COMPLETED

(I:SharedDocuments/Document Templates/GPS New_pt_reg_form ) (Revised July

2015/)Patient Registration Questionnaire

YOUR PERSONAL DETAILS NHS No:

Surname Forename(s)

Date of Birth Marital Status

Address

Post Code

Home Tel Mobile

Place of Birth Occupation

E-mail

YOUR CURRENT / PREVIOUS GP’S DETAILS

Address

Tel Number

CONSENT FOR EMAILING AND TEXTING SERVICES

 I consent to receiving text messages for appointments, reminders etc Yes / No Date

 I consent to receiving email messages for appointments, reminders etc Yes / No Date

ONLINE SERVICES ACCESS

 I wish to be able to book appointments and prescriptions online Yes / No Date (If Yes: please see application form enclosed)

ETHNICITY (Please circle as appropriate)

White Mixed Black Asian Chinese White British White / Black Caribbean Black British Indian White Irish White / Black African Black Caribbean Pakistani White European White / Asian Black African Bangladeshi Other Black Other Asian background Background Any other ethnic category ; please state

 Main Spoken Language

NEXT OF KIN : Name: Relationship:

Contact details:

PROFILE

Weight Height

Blood Pressure Systolic BP Diastolic BP Pulse Rate

SMOKING HABITS

Please circle the appropriate smoking habit;

Smoker Never smoked Ex-smoker

Smoker Ex-Smoker

What do you smoke? When did you stop smoking?

How many times per day?

If you would like HELP to QUIT SMOKING please book an appointment at reception

EXERCISE

No exercise / little exercise / Regular exercise  Do you get: (please delete as appropriate)

 If yes, what sort of exercise?

 How many times per week?

FAMILY HISTORY

Does anyone in the family suffer with the following? If so please state who

Condition Who? Date of onset/diagnosis  Heart Disease ( heart attacks, angina)  Stroke  Diabetes

ALCOHOL HABITS (Aged 16 & over)

One alcohol unit equals one 25ml single measure of whisky (ABV 40%), or a third of a pint of beer (ABV 5-6%) or half a standard (175ml) glass of red wine (ABV 12%).

Please complete the following by circling the appropriate answer:

Do you drink alcohol? YES / NO Estimated units per week: ______

How often do you have 8 (men) 6 (women) or more drinks on one occasion? 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

How often during the last year have you failed to do what was normally expected of you because of drinking? Never / Less than monthly / Monthly / Weekly / Daily or almost daily

In the last year has a relative or friend, or doctor or other health worker been concerned about your drinking or suggested that you cut down? No / Yes / On one occasion

CURRENT MEDICATION

Please give details of any medication which you take (prescribed or otherwise):

Name of Drug Name of Drug Dosage Dosage

Would you like to nominate a Pharmacy for prescriptions? Yes / No If Yes all future prescriptions will be sent electronically to your nominated pharmacy

Pharmacy Name and address:

ALLERGIES

 Are you allergic to any medication? If yes please detail Yes / No

 Are you allergic to any substances or foods? If yes please give details Yes / No

CARERS

 Do you have anyone who looks after you or your daily needs as a Carer? Yes / No  If YES, would you like them to deal with your health affairs here? Yes / No

Please provide details of your Carer

DO YOU LOOK AFTER SOMEONE WHO IS ILL, FRAIL, DISABLED OR MENTALLY ILL?

If so, you are a carer and we would like to support you. Please complete the following details.

If you are agreeable, we will pass your details to the Solihull Carer Centre, which is a borough-wide organisation providing relevant information and advice, local support services, newsletter and telephone helpline for carers.

We will also refer you, with your permission, to have your needs assessed by Adult Care Services, Social Services. A Carers Assessment is a chance to talk about your needs as a carer and the possible ways help could be given. It can also look at the needs of the person you care for. This could be done separately, or together, depending on the situation. There is no charge for an assessment.

DETAILS OF THE PERSON YOU LOOK AFTER

Date of Birth:

Address: If different from yours

Post Code:

Telephone No: If different from yours

GP Details If different from your own

Please pass my details to the Solihull Carer Centre

Please refer me to Adult Care Services for a Carers Assessment

ARMED FORCES

Are you a veteran of the Armed Services? YES / NO If yes, which service?

Are you in the employ of the Armed Services? YES / NO If yes, which service?

PAST MEDICAL HISTORY

Please give details of any significant past medical history or hospital treatment:

Whilst you are under no obligation to answer the following question, this information allows the Practice to ensure services are provided where they are needed and that our healthcare is tailored to your individual needs. Please remember that all staff with the Practice are bound by strict rules of confidentiality and we will not disclose any information about you without permission

Which of the following options best describes how you think about yourself?

Heterosexual ( ) Lesbian ( ) Homosexual ( ) Bisexual ( )

Thank you for completing this questionnaire.

For further information about our services, practice, team and links to useful resources please visit www.gpshealthcare.co.uk

When you have completed this form please return it to reception along with some form of photo ID e.g. passport or driving licence, AND a utility bill or bank statement (within the last three months) of your current address.

For official use only

Form of identification seen…………………….……………….Staff initials……………….……….Date…………………….. Acceptable ID: passport / driving licence / utility bill - within the past three months, etc.,

Named registered GP: …………………………

DATA SHARING INFORMATION

HOW WE CAN USE YOUR DATA TO IMPROVE YOUR CARE – YOUR CHOICES You need to let us know if you wish to opt-out of any of the schemes detailed below.

Name...... Date of birth……………………………………

Signature...... Date…………………………………………….

The following service is an “Opt-In” Service. You do need to complete the section below so that we can record your wishes. If you don’t complete and return this form you will be asked when you attend the surgery, so please do read and consider your choices.

Name...... Date of birth:……………………………………

Signature...... Date……………………………………………..

GPS Healthcare

Registration to use the Internet Appointment Booking Facility

To use the internet booking facility you need to register for the service.

You will be given your own unique User Name and Password which you should keep safe. GPS Healthcare reserves the right to remove a patient’s login privilege if the system is abused in anyway e.g. repeated failure to attend appointments booked on the internet.

Please complete the following details and hand in to the receptionist. You will then be given a letter with your User Name and Password.

Address

Date of Birth

Telephone Number

Mobile Number

Email address

I agree to keep my User Name and Password private and only use it to make appointments for myself. I understand that abuse of the system will result in losing the facility to book appointments on the internet.

Signed

Print Name

Please reply to main address. All post will be circulated to the recipient electronically.

Date: NHS No:

Named Usual GP

You may be aware that from April all practices are required to provide all their patients with a named GP.

Your Named Accountable GP is

Your Named GP will have overall responsibility for the care and support that our surgery provides to you. This does not prevent you from seeing any GP in the practice as you currently do.

You do not need to take any further action, but if you have any questions, or wish to discuss this further with us, please contact us on 0121 796 2777 or at [email protected]

Yours sincerely

For and on behalf of GPS Healthcare Partners