POSTCODE:
PHONE/MOBILE NO:
PleasePlease Choosesend Text RemindersDO NOT send Text Reminders to me
FAMILY / SURNAME:
(As it should be on your Passport):
MALE/FEMALE Please chooseMan/Boy/MaleLady/Girl/Female
TITLE
Please chooseMrMrsMissMsDrProf / DATE OF BIRTH :
01230123456789 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 192001234567890123456789
TOWN & COUNTRY OF BIRTH:
THIS IS VERY IMPORTANT, WE HAVE TO MATCH TO YOUR OLD MEDICAL RECORDS IN ENGLAND, SCOTLAND & WALES
Please answer ALL that apply
THIS IS MY FIRST EVER NHS DOCTOR IN ENGLAND, SCOTLAND or WALES (State arrival date)
I HAVE JUST RETURNED FROM ANOTHER COUNTRY BUT HAVE HAD AN NHSDOCTOR IN ENGLAND, SCOTLAND or WALES BEFORE (State date left for more than 6 months & when was your most recent return )
YOUR MOST RECENT NHS REGISTRATION: (Don’t include A&E attendances. We need the name of the Doctor or name of the practice) NHS NUMBER (10 numbers):
WHICH ETHNIC GROUP DO YOU BELONG TO: - (I DO NOT WISH TO ANSWER )
WHAT LANGUAGE DO YOU USUALLY SPEAK?
IF YOUR FIRST LANGUAGE IS NOT ENGLISH, DO YOU SPEAK ENGLISH REASONABLY WELL? YES
I NEED AN INTERPRETER
Please chooseNever SmokedI have stopped smokingI want to stop smokingI dont want to stop Smoking / HEIGHT
WEIGHT
Please state the units / FOR WOMEN OVER 24ONLY
YOUR LAST SMEAR TEST ?0123?0123456789 / Please chooseI am MaleI have never had oneMonth unknownJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 20191801234567890123456789
WHAT WAS THE RESULT
ALCOHOL USE - A standard drink is equivalent to a half pint of ordinary strength (4% abv) beer, lager or cider, 1 small glass of wine (8-10% abv in a 125ml glass) or 1 single pub measure of spirits or aperitifs
HOW OFTEN DO YOU HAVE A DRINK CONTAINING ALCOHOL?
Please chooseNever (score 0)Monthly or less (score 1)2-4 times a month (score 2)2-3 times a week (score 3)4+ times a week (score 4) / HOW MANY ALCOHOLIC DRINKS DO YOU HAVE ON A TYPICAL DAY?
Please choose1 or 2 (score 0)3 or 4 (score 1)5 or 6 (score 2)7 or 9 (score 3)10+ (score 4) / HOW OFTEN DO YOU HAVE 6 OR MORE ALCOHOLIC DRINKS IN ONE DAY?
Please chooseNever (score 0)Less than monthly (score 1)Monthly (score 2)Weekly (score 3)Daily or almost daily (score 4)
ADD YOUR SCORES TOGETHER, WHAT DID YOU GET?. If your score is 5 or above for a male or 4 and above for a female, you should think about your intake levels. If you need help, please ask at reception.
DO YOU HAVE ANY SPECIAL NEEDS / REQUIREMENTS IN ORDER TO ACCESS THE SERVICE WE PROVIDE?
PREVIOUS UK ADDRESSES:
/ CURRENT MEDICATION:
Please ask for an appointment to arrange to receive these from us. Thank You
PREVIOUS NAMES (Please state full name):
Every patient has to be allocated to a ‘Usual GP’, who would you like to beyours:-Please Choose OneDr Anjum (Male)Dr Khunti (Female)Dr Browne (Female)Dr Garcea (Female)Dr Andrews (Female)Dr Raja (Female)Dr Hussain (Female)Dr Shah (Female)Dr Patel (Female)Dr Vindhani (Female)Dr Fernando (Female)Dr Uma Mahalingappa (Female)Dr Bashaga (Female)
I APPLY TO REGISTER WITH VICTORIA PARK HEALTH CENTRE, I CONFIRM THAT I AM PERMANENTLY LIVING IN LEICESTER OR I AM IN LEICESTER UNTIL(Please state approximately when you expect to be leaving)
- Summary Care Record (emergency service access to summary information from your records) will be allowed unless you complete an ‘OPT OUT’ form both available from our website or Reception.
- Your medical records can be shared with otherNHSservices:Please chooseALLOWDENY
- Your medical recordsheld at otherNHSservices can share their information with us: Please chooseALLOWDENY
- Local Data Retrieval (for purposes of predicting potential future health needs of individuals and/or whole populations – more information available on our website) : Please chooseALLOWDENY
DATE 01230123456789 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 20191816789
SIGNATURE OR EMAIL ADDRESS ……………………………..……………