NEW PATIENT REGISTRATION FORM
The following information is needed to enable us to register you with this practice.
It is very important that the information is as accurate as possible.
If the Registration Form is not fully completed we may not be able to register you.
Please ensure that the alcohol screening document is completed and handed in.
A separate Registration Form will need to be completed for each family member.
Completed form(s) must be handed to a member of the reception staff for checking.
Please do not send by mail.
PLEASE USE BLOCK CAPITALS
1) Sex Male Female / 2) Title Mr Mrs Ms Dr Other / 7) EthnicityWhite Mixed
White British White & Black
White Irish Caribbean
White other White & Black
Black/Black British African
Black Caribbean White & Asian
Black African Other
Asian/Asian British Other ethnic
Asian Indian group
Asian Pakistani Decline
Asian Bangladeshi Decline to say
Asian other
Chinese/Chinese British
ChineseF
First Language
3) Family Name (surname)
4) First Name
5) Date of Birth
Day Month Year / NHS Number:
8) House Number & Street / 10) Home Telephone No:
11) Mobile No:
9) Postcode / 12) Email
Em113) E 13) Next of Kin. please provide details of who we may contact in an emergency:
Name: Name: Telephone Number:
Relationship to you:
Please provide as much medical history as you can below
Smoking statusI have never smoked / I am a current smoker, and smoke / I am an ex-smoker and used to smoke
less than 1 per day / less than 1 per day
1 to 9 per day / 1 to 9 per day
10 to 19 per day / 10 to 19 per day
20 to 39 per day / 20 to 39 per day
More than 40 per day / More than 40 per day
Date stopped:
Alcohol Consumption / Exercise
In an average week how many units of alcohol do you drink?
------Units
Note: 2 units = a pint of beer, 1 unit = one glass of wine, 1 unit = single measure of spirits or 3 units = two “alcopops” / In an average week how often do you exercise?
no regular exercise
1 to 3 twenty minute sessions per week
More than 3 twenty minute sessions per week
I am a competitive athlete
Note: Twenty minutes of vigorous walking counts as 1 exercise session.
Height / Is this measurement in metres centimetres feet and inches
Weight / Is this measurement in kilograms pounds stones and pounds
Blood
Pressure / This measurement can be taken by yourself, your pharmacist or you can book
with the healthcare assistant at the surgery. (please bring this form with you)
Any significant health problems – if yes please give year of diagnosis:-
Atrial Fibrillation
Absent spleen (Asplenic)
Asthma
COPD (e.g. emphysema or chronic bronchitis)
Coronary heart disease (e.g. heart failure, myocardial infarction and angina)
Current kidney disorders
Depression
Diabetes Type
Epilepsy
High blood pressure
Hypothyroidism
Stroke/CVA/TIA
Any other significant problem (Please detail)
Stroke
Diabetes Type 2
Other – please specify
Any medical history in blood relatives under 65 years of age
Heart disease Diabetes High Blood Pressure Asthma Other ………………………………………………………………
Medicines – If you take medication regularly (including contraception, tablets, cream and inhalers) you will need to book an appointment with a doctor so that they can review your medication and organise future repeat prescriptions. PLEASE BRING YOUR MEDICATION OR A LIST OF YOUR MEDICINE TO THE APPOINTMENTAllergies or Reactions – Give details if you have had any allergic reaction to: eggs,
medicines, vaccinations, medical dressings or foodstuffs.
Females Only
Cervical Smear Test / Have you ever had an abnormal smear? / Yes / No
When is your next smear due? (if known)
Are you pregnant? / No Yes - number of weeks ( )
If yes please book an appointment with our midwife
Is it OK to contact you:- by Phone By Email By Text
We will use the contact details you have provided on this form to contact you when necessary. If you prefer not to be contacted by any of these methods please let us know. Finally, to complete the registration process please sign the attached GMS1 form and return everything to the practice. Please familiarise yourself with the services we provide by reading the practice leaflet and please visit our website Streetlanepractice.com
Thank you and welcome to Street Lane Practice
FAST Alcohol Screening Test
Please complete the details below
If you feel that you need help or advice about an alcohol related issue
Please make an appointment to see the doctor.
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
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
Only answer the following questions if the answer above is Monthly (1) or Less than monthly (2). Stop here if the answer is Never (0), Weekly (3) or Daily (4).
How often during the last year have you failed to do what was normally expected from you because of your drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? / No / Yes, but not in the last year / Yes, during the last year
Scoring:
A score of 0 on the first question indicates FAST negative
A total of 1 – 2 on the first question then continue with the next three questions.
A total of 3 – 4 on the first question stop screening at first question.
An overall total score of 3 or above is FAST positive.
Summary Care Record
Emergency Care Summary
The Summary Care Record is information from your medical record that may help another clinician especially if you need any emergency treatment.
The information is very basic and limited to your current medication, any allergies and any bad reactions that you may have had to any medication.
Personal information is limited to your name, address date of birth and nhs number
At some point in the future you may want to add other details about your care to your Summary Care Record this is optional and would need to discuss this with one of the healthcare professionals treating you.
Having the basic information helps provide you with safer care during an emergency, especially when your practice is closed or you are in another part of the UK.
You will be able to look at your summary care record at a secure web site called Health Space. You need to register to use health Space to keep it as secure as possible, more information is available at www.healthspace.nhs.uk
If you have already opted out at your previous practice no information will be uploaded to the secure site, if you wish to now opt in please let the reception staff know.
Summary Care Record information from this practice will be available on the site after January 2013.
If you would like more information you can:
· Phone the Summary Care Record information line 0300 123 3020
· Contact your local Patient Advice and Liaison Service (PALS) www.pals.nhs.uk
· Or visit www.nhscarerecords.nhs.uk