willow tree family doctors
On-line Services
Willow Tree Family Doctors, using EMISPatient Access, offers internet access to our appointment system , repeat prescription ordering, viewing medical records and test results and amending your details
This complements our automated telephone appointment system access (Patient Partner) and gives our patients unrivalled ability to book, change or cancel appointments at any time of the day or night.
By using these systems we hope to improve our service to you and also help reduce the pressure on the busy telephone system, making it easier to contact the surgery when you need. You can of course still speak to a receptionist for your appointments but you now have the choice!
First name ______Surname______
Date of Birth______
Email address
I wish to register for Onn-line Services. Signed: ______
Please hand this form to a receptionist and show your proof of identity.
An email will be sent within 5 working days. Please tell us if this does not happen.
Receptionist ______Proof of identity ______Date______
willow tree
family doctors
Patient Care Text Messaging (SMS) Consent Form
Would you like to receive appointment reminders / general information about the practice?
If so, please complete and return the consent form to us as soon as possible.
Declaration
I consent/do not consent* (*please delete as appropriate) to the practice contacting me by text message for the purposes of health promotion and for appointment reminders.
I acknowledge that appointment reminders by text are an additional service and that these may not take place on all / or on any occasion, and that the responsibility of attending appointments or cancelling them still rests with me. I can cancel the text message / Email facility at any time.
The surgery does notgenerally offer a reply facility to enable patient to respond to texts directly but will do so for specific campaigns.
Text messages are generated using a secure facility however I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure, however the practice will not transmit any information which would enable an individual patient to be identified.
I agree to advise the practice if my mobile number changes or if this is no longer in my possession.
Patient name:
Mobile number:
Email address:
Date of Birth:
Signature: ______
Date:
This practice does not share mobile phone contact / email details with any external organisation
The GPs
Willow Tree Family Doctors
willow tree
family doctors
Family Name / First Name / Date of Birth / Your ethnic group(required by the NHS for monitoring)
Are you fluent in English? / Y/N / If not, what language/s do you speak? / Do you require an interpreter? / Y/N
Are you a carer? / Y/N / Do you have a carer looking after you? / Y/N / Are you a refugee or asylum seeker? / Y/N
NEXT OF KIN DETAILS
Next of kin: Name & Relationship / Next of Kin Address / Next of Kin Telephone number
Have any of yourclose family (parents, grandparents ,brothers or sisters) suffered from:
Heart disease / Y/N / High Blood Pressure / Y/N / Diabetes / Y/N / Asthma / Y/N
Glaucoma / Y/N / Epilepsy / Y/N / Any Others? details below
Cancer / Y/N / Mental Health problems e.g. depression / Y/N
Haveyou suffered from any Medical Conditions? Please give details incl. approx. dates of diagnosis, treatments, including operations & any hospital you are under and any handicaps you suffer:
Are you awaiting any Test Results? / Y/N / Details:
What is your job? (or are you unemployed or not working due to sickness?)
Have you ever smoked tobacco? / Y/N / Do you now? / Y/N / If you smoke how many per day?
Do you drink alcohol? / Y/N / If so, how much in a typical week? / Pints of beer / Glasses of wine / Measures of spirits
Have you ever had a drink or drugs problem? / Y/N / When were your last vaccinations? / Tetanus / Polio / Rubella / Travel
Please list any regular Medication you take, including the strength and how often you take it:
Are you Allergic to any medicines? / Y/N / If so, which?
FOR WOMEN:
Have you been checked for Rubella Immunity? / Y/N / If so when? / When was your last smear test? / Was it done at your GP surgery? / Y/N
What do you use for contraception? / Are you currently pregnant?
Thank you!
willow tree
family doctors
AUDIT-C QUESTIONNAIRE - ALCOHOL USE
Name: Date:
NHS No: DOB:
For the following questions please tick the answer which best applies. / 1 drink = 1/2 pint of beer or 1 glass of wineor 1 single spirits
- How often did you have a drink containing alcohol in the past year?
0 / Monthly or Less
1 / Two to four times a month
2 / Two to three times per week
3 / Four or more times
a week
4
- How many drinks did you have on a typical day when you were drinking in the past year?
0 / 3 or 4
1 / 5 or 6
2 / 7 or 9
3 / 10 +
4
- How often did you have six or more drinks on one occasion in the past year?
0 / Monthly or Less
1 / Monthly
2 / Weekly
3 / Daily or almost Daily
4
Total for Each Column: / Total
AUDIT-C Screening: / If score 5 or more complete the full AUDIT-10 below
Total AUDIT-C Screening: / If score 5 or more complete the full AUDIT-10 below
- During the past year, how often have you found you were not able to stop drinking once you started?
0 / Less than Monthly
1 / Monthly
2 / Weekly
3 / Daily or almost Daily
4
- During the past year, how often have you failed to do what was normally expected of you because of drinking?
0 / Less than Monthly
1 / Monthly
2 / Weekly
3 / Daily or almost Daily
4
- During the past year, how often have you needed a drink in the morning to get yougoing after a heavy drinking session?
0 / Less than Monthly
1 / Monthly
2 / Weekly
3 / Daily or almost Daily
4
- During the past year, how often have you had a feeling of guilt or remorse after drinking?
0 / Less than Monthly
1 / Monthly
2 / Weekly
3 / Daily or almost Daily
4
- During the past year, have you been unable to remember what happened the night before because you had been drinking?
0 / Less than Monthly
1 / Monthly
2 / Weekly
3 / Daily or almost Daily
4
- Have you or anyone else ever been injured as a result of your drinking?
0 / Yes but not in the past year
2 / Yes, during the past year
4
- Has a relative, friend, doctor or other health worker been concerned about your drinking or suggest you cut down?
0 / Yes but not in the past year
2 / Yes, during the past year
4
Total for Each Column:
Total
AUDIT Screening:
(don’t forget to add the Audit-C score!) / A score of 8 or more indicates harmful or hazardous drinking
A score of 13 or more in women and 15 or more in men indicates likely alcohol dependence