Bewbush Medical Centre Bewbush Place Crawley West Sussex RH11 8XT Telephone: 01293 592230 Dr N Storer, Dr R Kottyal, Dr M Chaudhry Fax: 01293 592231 ______

Bewbush Medical Centre Bewbush Place Crawley West Sussex RH11 8XT Telephone: 01293 592230 Dr N Storer, Dr R Kottyal, Dr M Chaudhry Fax: 01293 592231 ___________________________________________________________________________________________________ NEW PATIENT HEALTH QUESTIONNAIRE (PATIENTS AGED 14+) INTRODUCTION This questionnaire will help to establish a base line view of the patient life-style and will assist the HCA/Nurse in carrying out a new patient health check. PATIENT DETAILS Name_______________________________________________ Date of Birth___________________ Weight (kg)_________________ Height (cm)_________________ SMOKING Do you smoke Yes ( ) No ( ) If yes, how many per day?_________ EX SMOKERS If you used to smoke, how many did you smoke per day? _________ If you used to smoke, how old were you when you stopped?_________ ALCOHOL QUESTIONS 0 1 2 3 4 Your Score How often do you have a drink that Monthly or 2 – 4 times 2 – 3 times 4+ times per Never contains alcohol? less per month per week week How Many standard alcoholic drinks do you have on a typical 1-2 3-4 5-6 7-8 10+ day when you are drinking? N/A ( ) How often do you have 6 or more Less than Daily or Never Monthly Weekly standard drinks on monthly almost daily one occasion? ETHNICITY QUESTIONNAIRE This part of the questionnaire follows the recommendations of the commission for Racial Equality and complies with the Race Relations Act. Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problem are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions. Please tick the most appropriate option from the following list, providing more details if requested. Please also tick yes or no to questions F-I. White: Asian: White British □ Indian or British Indian □ White Irish □ Pakistani or British Pakistani □ White European □ (please specify below): Bangladeshi or British Bangladeshi □ ________________________________________ Other Asian background □ (please specify below): Other White background □ (please specify below): _________________________________________ ________________________________________ Black / African / Caribbean / Black British: Mixed: Black British □ Mixed British □ (please specify below): Caribbean □ ________________________________________ African □ White and Black Caribbean □ Other Black background □ (please specify below): White and Black African □ _________________________________________ White and Asian □ Other Mixed background □ (please specify below): Other: ________________________________________ Other ethnicity □ (please specify below): _________________________________________ I do not wish to state my ethnic group □ F Carer Please tick Yes ( ) No ( ) G Asylum seeker Please tick Yes ( ) No ( ) H Fostered Please tick Yes ( ) No ( ) I Adopted Please tick Yes ( ) No ( ) ACCESSIBLE INFORMATION STANDARD Do you have a disability that means you may require additional support with information or communication i.e. sign language or braille? Yes ( ) No ( ) If yes, please specify: ________________________________________________________________________ __________________________________________________________________________________________ Office use only Named accountable GP: Dr Nigel Storer ( ) Dr Rajeeven Kottyal ( ) Patient informed: Yes ( ) No ( ) CONSENT COMMUNICATION: Consent to receive communication by text message Yes ( ) No ( ) If yes, please provide mobile number: ______________________________________________ Consent to receive communication by email Yes ( ) No ( ) If yes, please provide email address: _______________________________________________ NEXT OF KIN/EMERGENCY CONTACT DETAILS: Name: ______________________________________________ Relationship to patient:___________________ Contact number: __________________________ Also a patient at Bewbush Medical Centre Yes ( ) No ( ) Do you give consent for staff at Bewbush Medical Centre to discuss and disclose all medical related issues with this contact? Yes ( ) No ( ) Please note that all patients aged 16 and over will need to provide written consent (as above) for Bewbush Medical Centre to be able to discuss and disclose any of their information with a third party including Parents/Guardians. SUMMARY CARE RECORD: The Summary Care Record (SCR) is a summary of your current medications, adverse reactions and allergies. This summary is uploaded to the NHS spine which is a secure database and is only accessed, with your consent, by medical staff in the event of an emergency, for example if you attend A&E, a walk-in-clinic or contact an out of hours service. All NHS patients are automatically opted in to the Summary Care Record, so please indicate if you would like to opt out below: I wish to opt out of the Summary Care Record ( ) More information about the Summary Care Record is available from the surgery upon request. ELECTRONIC PRESCRIPTION SERVICE (EPS): EPS allows us to send your repeat prescriptions electronically to a pharmacy of your choice. This makes the prescribing and dispensing process more efficient and convenient for patients. If you would like to take advantage of this service, please select your chosen pharmacy from the list below: Mannings – Bewbush ( ) Kamsons – Broadfield ( ) Gossops Green Pharmacy ( ) No pharmacy – Collect from Surgery ( ) Other, please specify: __________________________________ Please note that not all medications can be sent via EPS, the main example of which is controlled drugs. If you choose to nominate a pharmacy that is not specified above, please be prepared that you may be asked to collect your prescription from the surgery if it is not EPS compliant. Regardless of whether you choose to collect your prescriptions from the surgery or have them sent via EPS, when requesting your repeat prescriptions you must always allow 2 working days for your request to be processed. Please note that all decisions with regard to consent recorded on the previous page can be changed at any time in the future. Please ask a member of staff for assistance if you wish to do so. Signature of Patient _____________________________________ Print Name ____________________________________________ Date _________________________ Alternatively we can accept a proxy signature if the patient is under 16 years of age or lacks the capacity to sign (the latter may require GP input before we can accept). Signature of Proxy ______________________________________ Print Name ____________________________________________ Relationship to Patient ___________________________________ Date _________________________ .

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