New Patient Summary Sheet
New patient summary form -individual Hillview Medical Centre
Please complete all sections of the form1. Your details – please complete the boxes below
1.1 Name
(write in capital letters) / 1.2 Date of birth
1.3 Mobile phone number / 1.4 Home phone 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?
(please circle)
(internal use: add code 9NdS to patient record if ‘yes’) / Yes / No
1.6 (b) Are you happy for us to contact you by text?
(please circle)
(internal use: add code 9NdP to patient record if ‘yes’) / Yes / No
1.6 (c) Are you happy for us to leave messages for you on your answer phone? (please circle)
(internal use: add code 9Ndi to patient record if ‘yes’) / Yes / No
1.7 First language / 1.8 Do you need an interpreter? / Yes / No
1.8 Allergies / 1.9 Marital status
1.10 Are you a Carer?
If yes – please write in who for /
Yes / No / 1.11 How often do you usually visit your GP surgery?
(please tick) / Regularly
Occasionally
Very rarely
1.12 Would you like to help us to improve our services by joining our virtual patient participation group?
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. /
Yes / No
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 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 option / Tick 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 option / Tick 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
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 name
(please write in capital letters) / 3.2 Next of kin telephone number
3.3 Is your next of kin male or female?
(please circle) /
Male / Female / 3.4 How is your next of kin related to 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 white background / Black - any other black background / Pakistani
Any other Asian background
5. Do you smoke? - please tick the appropriate box underneath the options
Option 1
I have never smoked
(internal use – code 1371) / Option 2
I used to smoke
(please also write in the date when you stopped)
(internal use – code 137S) / Option 3
I am a current smoker
(please also write in how many cigarettes you smoke in a day)
(internal use – code 137R) / Option 4
I am a current smoker and would like the number for the Stop Smoking Service -
0845 602 3608
(internal use – code 8CAL)
6. How much alcohol do you drink? - please circle the appropriate boxes
( Please note - the scores are for internal use only) / Score 0 / Score 1 / Score 2 / Score 3 / Score 4
5.1 How often do you have a drink that contains alcohol? / Never / Monthly or less / 2 – 4 times per month / 2 – 3 times per week / 4 + times per week
5.2 How many standard alcoholic drinks do you have on a typical day when you are drinking? / 1 – 2 / 3 – 4 / 5 – 6 / 7 – 9 / 10 +
5.3 How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Signature / Date
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Saved in CQC under registration \ new patient registration pack – Sept 2014 Page 4 of 4