THE JUNCTION HEALTH CENTRE

Arches 5-8, Clapham Junction Station, Grant Road, London, SW11 2NU
Tel: 0333 200 1718 Fax: 0333 200 1719
Email:
Web:

NEW PATIENT REGISTRATION INFORMATION

In order to register as a regular patient at our surgery you must book New Patient Health Checkwith our HCA which will be a one off 25min appointment. All registration forms mustbe completed prior to your booked appointment. Please also ensure to arrive 15 minutes prior to the appointment to allow us to check all documents required.

Requirements – Please provide one of each of the following to your appointment:

  1. Proof of Address (must be dated within the last 3 months) – We will only accept Tenancy agreements, Utility Bills i.e. Electricity, Water, Council Tax, Telephone, Mobile Phone, Bank Statements including building societies and credit cards, Addressed payslips, TV Licence.

Please note: We DO NOT accept a UK Driver’s licence as proof of address

  1. Photo ID –
  • For British Citizens we only accept - Passport, UK Full Driving Licence, UK Birth Certificate.
  • European Citizens – Passport, European ID Card
  • Other – Passport & VISA
  1. Urine Sample - You will be required to provide a urine sample before the new patient health check. Please ensure you have a sample bottle before you attend this appointment (can be collected from reception).Please refrain from drinking anything for an hour before your appointment. When carrying out the sample please fill the sample bottle over half way full and ensure it is the first catch of your urine that enters the sample bottle.

Following this appointment, but not before, you will then be able to book an appointment with a GP or a Nurse. All GP appointments are a standard 10min and Nurses are 15min. Please let reception know if you will be discussing more than 1 problem with the GP.

* If a person does not have any proof of address in their name, they must produce a letter from someone at the address stating they live there and must produce a document from the address list in the 3rd parties name, who signed the document.

The Junction Health Centre – New Patient Questionnaire (ADULT)
Please fill this questionnaire in CAPITAL letters
Patient Details / Occupation:
Name: / Height (roughly if unknown): / Waist (in cm): / Weight (roughly if unknown):
Personal Status:
Single  Married Separated Divorced Civil Partnership Widowed  Other:______/ Exercise
Light Moderate Heavy Impossible
Date Of Birth: / Smoking Status
Address:
Postcode: / Never Smoked Ex-Smoker
Current Smoker - How many: ______per day.
Diet
Mobile No:
Home No: / Good Poor Average Vegetarian Vegan Low Salt Low Fat
Ethnic Origin / Medical History
White British White Irish Other White
Black Caribbean Black African
Other Black Black Caribbean & White
Black African & White Other Mixed
Indian Pakistani Bangladeshi Chinese Other Asian Do not wish to state
Other Ethnic Group- Please State below:
______ / Do YOU suffer with:
Asthma  Anxiety  Stroke 
Diabetes – Type 1  Mental Health  Atrial Fibrillation 
Diabetes – Type 2  Anorexia  Cancer 
Epilepsy  Bulimia  Obesity 
Depression  Hypothyroidism  Heart/kidney Disease 
Other - Please state: ______
Does ANYONE IN YOUR FAMILY suffer from:
High Blood Pressure CVA/ Stroke Asthma Heart Disease Diabetes Cancer Epilepsy Depression Other - Please state: ______
Next of Kin
Name:
Contact No:
Relationship:
Alcohol consumption / Language support
I don’t drink  - Ignore the rest of this section
I drink _____ units a week - Please fill out section below.
1. How often do you have a drink containing alcohol?
 Never (0)  Monthly or less(1)  2-4 times a Month (2)  2-3 times a Week (3)
4 or more times a week (4)
2. How many standard alcoholic drinks do you have on a typical day when you are drinking?
 1-2 (0)  3-4 (1)  5-6 (2)  7-9 (3)  10+
3. How often do you have 6 or more alcoholic drinks on one occasion?
Never (0) Less than Monthly (1) Monthly (2) Weekly (3)
Daily or almost daily (4) / What is your first/home language?
______
If your first/home language is not English, do you speak English:
Yes No
Do you use any of the following:
Sign Language: Yes No
Hearing aid: Yes No
Lip reading: Yes No
Are you any of the following:
Homeless: Yes No
Refugee: Yes No
Asylum seeker: Yes No
Depression Screen
1.During the last month, have you often been bothered by feeling down, depressed or hopeless?
Yes No
2.During the last month, have you often been bothered by having little interest or pleasure in doing things?
Yes No

For anyone aged 15 - 24 years of age

Chlamydia screening
Would you like to be tested for Chlamydia?
Yes No

For women only:

How did you hear about us? / Religion / Do you consider yourself to be a disabled person? / Smear details
Leaflet  / Christian  Buddhist Hindu
Jewish Muslim Sikh
No religion / Have you had a smear test before?
Newspaper  / No
Yes - Please specify below:
______/ Yes  No
If yes please state date of last smear ….../…../…..
Was it normal? Yes No
Where was it done?......
Word of mouth 
Internet  / Want to opt out? Yes Please Complete disclaimer
Walk-In Clinic  / Other – please state:
Other: / Disclaimer completed (internal use only)
______/ Do not wish to state