Surname______First name(s)______DOB___/____/___

ID Checked Passport/Driving Licence/ID Card/Other Staff initials ______

Welcome to Huntingdon Road Surgery Please complete all the pages and hand back to reception when finished!

Contact details - Itis your responsibility to ensure we have the correct contact details for you at all times
Home number: / ______
Mobile number: / ______
We will send you appointment confirmations and recall invites by text unless you advise us otherwise.
I do NOT want to be contacted by text 
Email address: / ______
I do NOT want to be contacted by email 
Language: / I can speak English  / Main language if not English ______
Occupation: ______Place of Birth: ______
What is your ethnic group?
White British  / White & black Caribbean  / Bangladeshi / Chinese 
White Other  / White and Asian  / Caribbean  / Other 
White & black African  / Pakistani  / Indian  / Decline to say 
Next of Kin
Name: ______Relationship: ______
Telephone number for next of kin:______
Carers/Foster Care/Social WorkersIf applicable
I have a carer  / Name of carer______Telephone ______
Relationship to you ______
I am a carer  / I would like to receive information about services 
Summary Care Records
Your Summary Care Record will only contain information about any medicines you are taking, allergies you have and any bad reactions to medicines that you have had.
Giving healthcare staff access to this information can help prevent mistakes being made when caring for you in an emergency or when the surgery is closed. Staff will ask you if they wish to access your Summary Care Record.
For further information OR call the Information Line on 0300 1233020
I am happy to have a Summary Care Record
YES NO Signed ______
The NHS will create a Summary Care Record for you unless you tell us not to do so
Sharing In and Out
You can now choose whether to share your full medical details. This includes your medical history, details about your medication and any allergies you may have.
Sharing your health record will help us deliver the best level of care for you. It will only be shared with other healthcare professionals providing care for you. This could include out of hours services, children’s services, community services and some hospitals. These other services will ask for your permission before they view your record.
SHARING OUT - controls whether your information recorded at this practice can be shared with other healthcare services.
I would like my record at this practice to be shared with other healthcare services providing care for me
YES NO Signed ______
SHARING IN - This determines whether or not this practice can view information in your records that has been entered by other services who are providing care for you—or who may provide care for you in the future.
I would like this practice to be able to view information in my health record that has been recorded by other healthcare services
YES NO Signed ______

MEDICAL Questionnaire

Medical History - Please also list any operations/serious medical problems:
Medication – Please list any medication you currently receive from your doctor
Allergies – Please list any known allergies / Vaccinations / Date
 / MMR 1st / → / ____/____/____
 / MMR 2nd / → / ____/____/____
 / Meningitis C / → / ____/____/____
 / Pneumococcal / → / ____/____/____
Online Services
You can order repeat prescriptions, make appointments and view your summary care records.
I would like to sign up for SystmOnline 
We will text/email your log-in details once your registration is complete.

LIFESTYLE questionnaire

SMOKING
I have never smoked
I am a current smoker
Number of smokes per day _____
If you do smoke and would like help stopping smoking, please make an appointment with the Smoking Cessation Clinic
I am an ex-smoker 
Date stopped: ______
Height______cm Weight ______kg/stone
ALCOHOL
On average how much alcohol do you drink in a week? ______units/week
How often do you have a drink that contains alcohol?
Never Monthly 2-4 times per month 2-3 times per week 4+ times per week
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+
How often do you have 6 or more standard drinks on one occasion?
Never Less than monthly Monthly Weekly Daily or most daily