Dr Jain & Dr Subramanian Adult Registration Questionnaire.

Surname:………………….First name:……………..Date of Birth:…………….

Current Address:………………………………...... Home Tel:…………………….

………………………………...... Post Code……………..

Previous Address:………………………………...... Home Tel:…………………….

………………………………...... Post Code……………..

Mobile Number:……………………….. Home Number: ………………………..

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

Woman (including trans woman) Man (including trans man) Non-binary

In another way
Please state):

Is your gender identity the same as the gender you were given at birth?

Yes No

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

Lesbian Bisexual Gay Heterosexual/Straight

In another way (Please state)

NHS number:……………………......

Main Spoke Language…………………….

Which of the following best describes how you think of yourself? Please tick one option

Asian or Asian British / Black or Black British / Mixed/Multiple Ethnicity / White
Bangladeshi / African / Asian and White / White British, English, Northern Irish, Scottish or Welsh
Chinese / Caribbean / Black African and White / White Irish
Indian / Black Caribbean and White / GRT
Pakistani
Any other ethnic Group (Please state)
Do you consider yourself to be a disabled person?
(This may also include long-term medical conditions) / Yes No

Summary Care Record & Information:

Tick this box to confirm that you wish to have a Summary Care Record created for you – this record contains information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Patient signature……………………………………….. Date………………………….

Enhanced Summary Care Record (Over 65 Only):

This this box to confirm that you wish to have an Enhanced Summary Care Record created for you. Any patient over the age of 65 we are required to offer to share your enhanced summary care record, this includes all information in the summary care record as well as any significant medical diagnoses, any significant treatments (e.g. immunisations and seasonal influenza dates) and any significant investigations (e.g. Gastroscopy and MRI scans results).

Patient signature……………………………………….. Date………………………….

General History:

What medical conditions do you suffer from? and what medications do you currently takefor this?

…………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………

Do you smoke Y / N / EX- Quantity…………………..

Do you drink Y / N

Questions / Scoring system / Your score
0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly
or less / 2 - 4 times per month / 2 - 3 times per week / 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? / 1 -2 / 3 - 4 / 5 - 6 / 7 - 9 / 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Family History:

Which of your blood relations have suffered

from the following:

Heart attack………………… Cancer……………

Diabetes……………….Asthma………………..

High blood pressure……….……....TB…………

Stroke…………. ……Other………………….

Are you a carer? (Someone who is looking after a family member, partner or friend who needs help because of illness, frailty or disability and not being paid for this)

I’m a full-time carerI’m a part-time carer I’m not a carer

Have you ever served in the armed forces? Yes No

Female Patients Only:

Have you any children?...... Give ages……...…..

Have you had a miscarriage?...... Date………….

Have you had a hysterectomy?...... Date………….

Which method of contraception are you using at present?......

When was your last smear test?......

Thank you very much for taking the time to fill out this information.

This will remain strictly confidential.

Dr Jain and Dr Subramanian

Online Patient Access Disclaimer

I (the patient) am requesting access to my own records online through the Vision Patient Services with the ability to access appointments, ordering repeat prescriptions and access to my basic medical records. I therefore take full responsibility for access to my account, not allowing anyone else access with my username and password.

Patient Details:

Forename: ______Surname: ______

DOB: ____/____/____ Address:______

______

______

Contact Telephone/Mobile Number: ______

Email address:______

*If you are completing this form for a patient(s) tick this box:

Relationship to the patient: ______

Name: ______Signature & Date: ______

Children under the age of 16 will not currently be covered by our online services.

Review & terms and conditions

Please return your completed application to the surgery

Terms & Conditions of use

  • Patients must be at least 16 years to register for the service.
  • The practice will only accept signed applications from individual patients for their own registration details. (For example a wife cannot request registration on behalf of her husband).
  • Patients will be required to prove their identity as part of the registration process. You will be asked to provide 2 suitable forms of identification. You will need to present a photo ID which shows your address details for example a photo driving licence. If you don’t have a photo driving licence you will need a passport and also a utility bill with your address clearly shown.
  • Use of your security details by an unauthorised person may allow them access to confidential medical information about you; therefore these details must be kept confidential at all times.
  • Your security details must be kept safe and secure at all times.
  • Patients must NOT share their security details to any other person including family and practice staff. We will NEVER ask you for your security details. If someone asks you for these details please inform the practice immediately.
  • You must use all reasonable precautions to protect your security details. This includes not using a public computer for access to the service and using the log off icon when you have finished with the service.

Terms of Use
This Website is offered as a free service to you, the User. Your use of this Website and/or your acceptance without modification of the terms, conditions, and notices contained herein constitutes your agreement to all such terms, conditions, and notices.

If you do not agree with these terms and conditions then you may not use this Website.

This websitehas beencreated for the sole purpose of providing useful health information and resources for the patients and staff of Dr Jains and Dr Subramanian’s Practice.

General
While using the website, it is expressly forbidden to transmit obscene or offensive content, disrupt the normal operation of the website, or cause offence, distress, or inconvenience to any person. It is prohibited to copy, adapt, download, make available to the public, or otherwise distribute website content, except with prior permission. This website is controlled and updated by the surgery from its offices in the United Kingdom; therefore these terms shall be governed by and interpreted in accordance with the laws of England and Wales.

Security

The Vision Online service has been developed, tested and accredited by a government body called NHS Connecting for Health. All personal information used is secure and protected. It is only available to staff at your practice that have the appropriate security controls, i.e. those managing appointments, repeat prescribing and patient registration.

We regard all your online information as confidential information so we want to safeguard you by asking that everyone who registers to brings along some form of identification before we issue your username and password. If you are housebound please contact the surgery for a home visit from the nurse who can go through the form with you and bring it back to the surgery. We will then send you your username and password by post in an envelope marked ‘Private and Confidential’.

Final Word
Please always consult a doctor or other healthcare professional if you require medical help.

Declaration

I confirm that the information provided on this application is correct to the best of my knowledge. I have read, understood, and will adhere to, the Practice Guidance for the use of Vision Online and understand that failure on my part to adhere to the guidance may result in my online registration being suspended or terminated without prior warning and that this will in no way affect my registration with the practice. I agree to keep my security details safe and secure at all times and will take all reasonable measures to prevent unauthorised access to the service. I also acknowledge that Dr Jain and Dr Subramanian cannot be held accountable for any inconvenience, loss, damages or costs incurred as a result of the online booking system malfunctioning or being otherwise unavailable at any time.

I have read, and agree to abide by Dr Jain and Dr Subramanian’sTerms & Conditions

Signature: ______Date: ______

Please tick the online services that your require

Online appointments:

Repeat Prescriptions:

Access to your basic health record:

Access to health record will be enabled at a later date by your named Doctor when your record has been checked and verified.

Office use only:

Photographic ID must be photocopied to confirm the patient’s identity. The ID and this document must be scanned into the patient record for future reference and then given to the Practice Manager.

Two forms of ID are needed:

1 – Photo I.D. (Passport/Driving License) Shown: Copied

2 – Utility Bill showing patients current address (within last 3 months) Copied

Taken by (Staff name): ______

Date: ______

For Manager to Complete:

Codes added to record (91B & 93440)

Checked by named GP

Online Access to Medical Record - A Guide for Patients

Dr Jain and Dr Subramanian have enabled online access for our patients to order repeat prescriptions for a number of years. This year we have successfully extended the service so that our patients can also book appointments online. We now have the option to open up your medical record for you to view a summary of your record and your test results using the same computer system.

In developing this service, we have worked closely with our Patient Advisory Group. Listed below are some of the questions we think you may want answered to help you decide if you wish online access to your medical record and test results.

  1. Is this compulsory?

No. If you do not want to use this you do not have to and you can just carry on as before. You will still be able to order your prescription and book appointments online even if you do not wish access to your medical record.

  1. What will I be able to see?

A summary of your important current and past medical conditions and procedures

Medications

Allergies recorded in your record

  1. Can I alter the record?

No. This is a ‘read only’ facility. You can however print off details to take abroad or to a hospital appointment. If you think there is an error or omission, you need to contact the practice.

  1. What are the advantages for me?
  • You will be able to view your record at home, overseas, at hospital or whenever you want access and have internet connection
  • You can check your record for accuracy to help the practice ensure you receive best care
  • It is secure
  1. What are the risks for me?
  • There may be something in the record that you do not want to be reminded about
  • Some terms may be difficult to understand as the record is primarily written for doctors and nurses to communicate about your care
  1. What about children?

We currently only allow Medical Record access to those aged 16 and over. We understand, however.

  1. Can I have access to the records of someone I care for?

We currently only allow Medical Record access to the patient. Again, we understand that it may be helpful if you are a carer for you to have access to the records of the person you care for. In some cases the patient may agree to share their record with the person who cares for them and this will be their individual decision. There may be occasions where a patient is not capable of giving her/his consent to patient record access eg in the cases of patients suffering from dementia. In these cases the practice will make an individual decision based on the knowledge and judgement of the clinicians involved in their care, in collaboration with the patient’s carers.

  1. Can you turn it off?

Yes. We can turn off the access in part or altogether if you wish. There also may be occasions when the practice considers it is in your best interest to turn it off. This decision would of course be discussed with you including the reasons why the decision has been made.

  1. What about security?

As with online banking, you control viewing by using your User ID and password. You will be responsible for keeping it safe and not revealing it to anyone.