HANDFORTH HEALTH CENTRE
WILMSLOW ROAD, HANDFORTH, CHESHIRE, SK9 3HL
TEL: (01625) 529421 / FAX: (01625) 536560PARTNERS
DR R E NEWHOUSE
DR J E SHIPSTON
DR J C MILLIGAN
DR S J HOLMES
DR A KAPOOR / / ASSOCIATES
DR R OLDHAM
DR R KUMAR
PRACTICE CODE: N81070
IMPORTANT INFORMATION
PLEASE READ BEFORE COMPLETION
Dear Sir or Madam
The registration process is a formal one. Your registration will not be completed unless all information is provided. It will take about 7 working days for the registration process to take place. During this time, you will still be registered with your previous GP and will be able to access a GP appointment and any medication. However, an emergency appointment will be offered if necessary.
To help staff with the process and to ensure there are no delays, I should be grateful if you would:-
- write clearly;
- ensure all sections of the forms are completed;
- provide all necessary documentation;
- return your documentation at a quiet time ie mornings after 9.30 and avoid lunchtimes where possible.
If you are unsure of any information such as your NHS Number (10 digit number) please contact your previous GP or write to Cheshire Health Authority, Patient Services, 1829 Building, Countess of Chester Health Park, Liverpool Road, Cheshire, CH2 1HJ or NHS Stockport, 8th floor Regent House, Heaton Lane, Stockport, SK4 1BS.
The Practice shares information through the Local care record, National Summary care record, also the Health and Social Care Information Centre. If you would like more information regarding this or wish to opt out of any of the above please ask reception for the relevant forms.
The practice offers a text reminder service for appointments. Any mobile phone numbers given will be used by the surgery to send out appointment reminders. If you do not wish to receive reminders please let the surgery know.
Please also note that we cannot accept patients from outside our practice area.
As a practice we have zero tolerance to rude, aggressive behaviour towards any members of staff or other patients.
Yours faithfully
Joanne Morton
Practice Manager
HANDFORTH HEALTH CENTRE
WILMSLOW ROAD, HANDFORTH, CHESHIRE, SK9 3HL
TEL: (01625) 529421 / FAX: (01625) 536560PARTNERS
DR R E NEWHOUSE
DR J E SHIPSTON
DR J C MILLIGAN
DR S J HOLMES
DR A KAPOOR / / ASSOCIATES
DR R OLDHAM
DR R KUMAR
PRACTICE CODE: N81070
INFORMATION REQUIRED
For security purposes, you will need to bring along to the surgery documentation to confirm your personal and residential identify. Please bring in one from List 1 and one from List 2:-
List 1 – to confirm your personal identity
- medical card;
- current passport;
- current UK photo card driving licence;
- Home Office residency permit/own country passport/VISA.
List 2 – to confirm address
- recent utility bill (not more than 3 months old);
- Council Tax bill (current year);
- Photo car/driving licence (if not used for personal identification);
- Bank statement (not more than 3 months old);
Could you also please answer the following questions:-
1Have you been registered at this practice before?YES/NO
2Are there any other family members or other contacts at your address please list:-
______
______
______
______
HANDFORTH HEALTH CENTRE
Welcome to our Practice. If you would like to make an appointment for a New Patient Health Check (over 5yrs old only) please ask at Reception. All patients aged 15 and over are required to complete this questionnaire prior to registering with us.
NEW PATIENT QUESTIONNAIRE – PLEASE COMPLETE FULLY
Date of Completion:Surname: / First names:
Date of Birth: / Tel No: (home):
Tel No: (mobile):
Tel No: (work):
Occupation:
Have you any current health problems? / No / Yes / (if Yes please give details):
Weight: / Height: / Allergies:
Are there any illnesses or diseases in the family? Yes No (If Yes please complete the following)
Heart Disease (under 60yrs of age)
Heart Disease (over 60yrs of age
Stroke
Diabetes
Asthma
Cancer: / Family relationship:
Family relationship:
Family relationship:
Family relationship:
Family relationship:
Family relationship:
If currently on medication please give us a copy of your repeat prescription (white side) as soon as possible. Would you like a local pharmacy to collect repeat prescriptions for you? Yes No
If Yes which pharmacy would this be?
Do you smoke? / Yes / No / Have you ever smoked? / Yes / No
If YES is it: / If Yes when did you give up?
Cigarettes / Cigars / Roll-ups / Pipe
How many per day do you smoke? / Are you a Carer or are you cared for?
No
Yes Please ask Reception for a Leaflet
Entered by Helen D
Aged 16 and over only:
Alcohol (no of Units):What is a unit?
1 unit= single measure of spirits
1.5 units= alcopop or can of lager
2 units= pint of regular beer/lager/cider
2 units= glass of wine (175ml)
9 units- bottle of wine
(Please circle the correct answer)
Questions / 0 / 1 / 2 / 3 / 4
How often do you have 8 (men) /
6 (women) or more drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or
almost daily
Only answer the following questions if your answer above is monthly or less
How often in the last year have you not been able to remember what happened when drinking the night before? / Never / Less than monthly / Monthly / Weekly / Daily or
almost daily
How often in the last year have you failed to do what was expected of you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or
almost daily
Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? / No / Yes but not in the last year / Yes, during the last year
TOTAL SCORE
(Add all 4 scores)
If your total score adds up to 3 or more please complete the Alcohol Questionnaire on the next page
Please will ALL patients complete the Ethnic Origin Questionnaire (attached)
HANDFORTH HEALTH CENTRE
PATIENT ETHNIC ORIGIN QUESTIONNAIRE
This 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 problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.
Choose ONE section from A to E, and then tick ONE box to indicate your background.
Name ...... Date of Birth ......
First Language: ......
A / WhiteBritish
Irish
Any other white background please write in below
B / Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background please write below
C / Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background please write below
D / Black or Black British
Caribbean
African
Any other background please write below
E / Chinese or other ethnic group
Chinese
Any other please write below
Version 1 – January 20101/6
Revision Date – January 2015
Ref – CQC/Administrative Protocols