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Brockwood Medical Practice

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Brockwood Medical Practice 1 2 NEW PATIENT QUESTIONNAIRE Name DOB I wish to have access to the following online services via Systm Online (Please ck all that apply) (you must provide your email address on page 1): 1. Booking appointments 2. Requesng repeat medicaons 3. Accessing my medical record (see below) f you wish to have access to your medical record online please speak to one of the receponists. You will be required to provide us with photographic proof of name and also proof of address. S MMARY CARE RECORD (SCR) A SCR is an electronic record that provides healthcare sta' with rapid access to essenal informaon about an individual in order to provide them with direct care and treatment. f you do not wish to have an SCR please ck this bo( CO NTRY OF BIRT,: Ethnicity-please choose from the list below: These are aligned to Census -uesons as recommended .y the Commission for Racial E/uality Ethnic 0roups White Brish Mi1ed Asian or Asian Brish White - Black Caribbean ndian White - Black African .akistani White - Asian Bangladeshi Any other Mi(ed background, please state: Any other Asian background0 please state: 111111111111111111111111111111111111 111111111111111111111111111111111111 Black or Black Brish Chinese or other ethnic group African Caribbean Any other Black background0 please state: Any other0 please state: 111111111111111111111111111111111111 111111111111111111111111111111111111 Signature of paent or Signature on .ehalf of paent Date 3 NEW PATIENT QUESTIONNAIRE Name DOB ,ave you previously .een a paent of either the MARITA6 STAT S: Brockham2 North ,olmwood or Newdigate Surgeries: Yes 3 No NE3T OF 4IN: Name: Mobile: Relaonship: Contact Tel(s): Email: ADDRESS: We will send you te(t messages3emails with appointment con6rmaon3reminders and informaon about services. f you do not wish to receive these please ck 0ENERA6 ,ISTORY: 9ave you had any serious illness, operaons, (-rays or similar tests, if yes please detail dates: SE3: Male 7emale OCC PATION: ,eight: FAMI6Y ,ISTORY: 5eight: ,ave any of your immediate family (under the age of 70) su9ered from any of the following: Relaon FEMA6E PATIENTS ON6Y: ,eart A:ack Yes/No When was your last cervical smear8: Dia.etes Yes/No What was the result8: Asthma Yes/No Stroke Yes/No Cancer Yes/No The 0overnment has a new alcohol ,igh Blood Pressure Yes/No iniave. Pease complete the a:ached Tu.erculosis Yes/No /uesonnaire and return to the surgery Other Serious Illness Yes/No together with your registraon forms. Signature of paent or Signature on .ehalf of paent Date 2 NEW PATIENT QUESTIONNAIRE Name DOB 5,AT MEDICINES ARE YO C RRENT6Y ,AVE YO EVER SMO4ED: TA4IN0?: Yes 3 No 3 E(-smoker f yes or e(-smoker, how much tobacco or cigare;es do3did you smoke per day8: ,AVE YO ANY A66ER0IES TO MEDICINES OR ANYT,IN0 E6SE?: When you are registered you may make a 20 minute appointment with a Practice Nurse for a New Patient Health Check—please bring a urine sample with you. ARE YO A CARER: Yes 3 No DO YO ,AVE A CARER (please give details): DO YO ,AVE A DISABI6ITY, IMPAIRMENT OR SENSORY 6OSS AND ,AVE ANY SPECIA6 COMM NICATION NEEDS?: Yes 3 No f yes please tell us below your speci6c communicaon needs, alternavely contact us directly to discuss your speci6c needs further. Signature of paent or Signature on .ehalf of paent Date 5 0-19 TRANS7ER 7ORM (under 5 years of age) G. SARGERY: 11111111111111111111111111 Last name 7irst name (s) Cate of Birth Se( Mother3Guardian 7ather3Guardian Child Child Child Child Child Telephone Number 9ome ,ork Mobile .revious3Other Address(es) New Address .revious G. .revious 9ealth Disitor3School Nurse .lease send to the RMC Referrals Management Centre (OEce hours 8amG6pm Mon-7ri): Email: CS9.ReferralsHnhs.net 7a(: 0208 392 3863 Tel: 0208 392 3868 0-19 Transfer n 7orm Dersion 1 6 This is one unit of alcohol… …and each of these is more than one unit AUDIT – C Scoring system Your Questions 0 1 2 3 4 score 2 - 4 2 - 3 4+ How often do you have a drink containing alco- Monthly times times times Never hol? or less per per per month week week How many units of alcohol do you drink on a typ- 1 -2 3 - 4 5 - 6 7 - 9 10+ ical day when you are drinking? Daily How often have you had 6 or more units if fe- Less or male, or 8 or more if male, on a single occasion Never than Monthly Weekly almost monthly in the last year? daily Scoring: A total of 5+ indicates increasing or higher risk drinking. SCORE I Score from AUDIT- C (other side) SCORE Remaining AUDIT questions Scoring system Your Questions score 0 1 2 3 4 How often during the last year have you Less Daily or found that you were not able to stop drinking Never than Monthly Weekly almost once you had started? monthly daily How often during the last year have you Less Daily or failed to do what was normally expected from Never than Monthly Weekly almost you because of your drinking? monthly daily How often during the last year have you needed an alcoholic drink in the morning to Less Daily or Never than Monthly Weekly almost get yourself going after a heavy drinking ses- monthly daily sion? How often during the last year have you had Less Daily or Never than Monthly Weekly almost a feeling of guilt or remorse after drinking? monthly daily How often during the last year have you been Less Daily or unable to remember what happened the night Never than Monthly Weekly almost before because you had been drinking? monthly daily Yes, Yes, but not Have you or somebody else been injured as a during No in the the last result of your drinking? last year year Yes, Yes, Has a relative or friend, doctor or other but not during health worker been concerned about your No in the the last last drinking or suggested that you cut down? year year Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence TOTAL TOTAL Score equals AAC T C Score (above) J Score of remaining quesons 8 BROCKWOOD MEDICAL PRACTICE Dr J D Richards Dr J R Thompson Dr L E Rawson Dr T A Sevenoaks Dr R P Gupta Dr A G Brett The Surgery, Tanners Meadow, Brockham RH3 7NJ Tel: 01737 843259 Fax: 01737 845184 The Surgery, Rusper Road, Newdigate RH5 5BE Tel: 01306 631242 Fax: 01306 631109 North Holmwood Surgery, 1 Bentsbrook Close RH5 4HY Tel: 01306 885802 Fax: 01306 882926 Website: www.brockwoodmedicalpracce.nhs.uk Email: [email protected] Brockwood Medical racce Welcome to Brockwood Medical Prac1ce and our 0rac1ce ,ooklet where we hope you will ,ene2t from a wealth of informa1on a,out the healthcare services availa,le at our Brockham, Newdigate and North Holmwood surgeries. There is more informa1on availa,le on our we,site: www.,rockwoodmedicalprac1ce.nhs.uk. Our 0rac1ce is ,ased in three purpose7,uilt surgeries in Brockham, North Holmwod and Newdigate. We cover an area of approximately 100 s8uare miles, ,ounded ,y Dorking and Reigate in the north and Charlwood and Rusper in the south. We are a training prac1ce and o:er a wide variety of services in a modern and friendly environment. WE ARE HERE TO HELP…. ONE CLIC% AWAY .ou can now access a num,er of services online; ordering a repeat prescrip1on, ,ooking or cancelling an appointment or accessing your medical records are ,oth just a click away. .ou will need to ,e provided with a uni8ue login username and password which you can o,tain ,y contac1ng your surgery. Both the username and password can ,e changed ,y yourself to something you may 2nd more suita,le. (EALT( AND (A INESS Our team are dedicated to your con1nued good health and approach your care with professionalism, discre1on and friendliness. .ou can count on a warm welcome from everyone involved here in the prac1ce. BROC%(AM O ENING TIMES Monday 0 .00 7 1 .30 Tuesday 0 .00 7 1 .30 Wednesday 0 .00 7 17.00 Thursday 0 .00 7 1 .30 ,riday 0 .00 7 1 .30 NEWDIGATE O ENING TIMES Monday 0 .00 7 1 .30 Tuesday 0 .00 7 17.00 Wednesday 0 .00 7 1 .30 Thursday 0 .00 7 1 .30 ,riday 0 .00 7 1 .30 NORT( (OLMWOOD O ENING TIMES Monday 0 .00 7 1 .30 Tuesday 0 .00 7 1 .30 Wednesday 0 .00 7 1 .30 Thursday 0 .00 7 16.00 ,riday 0 .00 7 1 .30 W(EN WE ARE CLOSED Outside of normal surgery hours emergency G0 cover is provided ,y NHS 111. 0a1ents can access the relevant out7of7hours service ,y calling: Brockham Surgery 01737 43259 or .-.-.. N(S ... NHS 111 gives access to local NHS healthcare services. .ou can call 17171 when you need medical help fast ,ut it is not a 999 emergency. NHS 111 is availa,le 24 hours a day, 365 days a year. Calls are free from landlines and mo,ile phones. In a genuine emergency you should call 000. Chest pains and1or shortness of breath constute an emergency . STA,, DETAILS Dr 3onathan Richards - MB, BS (London 19 6), DRCOG, MRCG0. D0D 7 Senior 0artner Special Anterests: Dermatology, G0 Training, Minor Surgery. Dr Tamsin Sevenoaks - MB, BS (London 19 9), DFF0 7 0artner. Special Anterests: Family 0lanning/Contracep1on. Dr Lucy E Rawson - BSc, MB, BS (London 19 9), DRCOG, DCH, MRCG0 7 0artner. Special Anterests: G0 Training, Child Health. Dr 3usn Thompson - MB, BS (NoCngham 19 5), B.Med.Sci, MRCG0, DCH 7 0artner.
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