Perranporth Surgery
Health Data Collection (16yrs+)
Name: ………………………………………………………………………………………………………………………………….
Date of Birth: …………………………………………………………………………………………………………………………
Home telephone number: ………………………………………………………………….………………………………….
Mobile number: ……………………………………………………………………………………………………………………
Email address: ……………………………………………………………………………………………………………………….
Please inform us if you have any specific communication needs, eg require large print letters. Please discuss your request with the receptionist when you register. We will then flag your notes to ensure that we meet your communication needs in future.
Declaration
oI consent to Perranporth Surgery contacting me by text message and/or email for the purposes of health promotion.
oI do not consent to text messaging
Please select as applicable.
I can cancel the text messaging facility at any time.
I agree to advise the practice if my mobile number changes or if this is no longer in my possession.
Signed:Date:
Perranporth Surgery - Monitoring Form
To help us improve our service, we would appreciate your time in completing this form.
In each section please tick the box which is appropriate to you.
First Language / EnglishOther
(please write this in)
ETHNIC GROUP
White / British
Irish
Cornish
Any other white background
Asian or Asian British / Indian
Pakistani
Bangladeshi
Any other Asian background
Mixed / White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Black or Black British / Caribbean
African
Any other Black background
Chinese or other Ethnic Group / Chinese
Any other
Your current / past medical history
Height : ………………………………………………………….. (You can measure these in the
Weight : ………………………………………………………… reception area of the surgery.
Blood Pressure : …………………./………………………. Just ask the receptionist.)
Do you have any allergies? If yes, please state : …………………………………………………………………….
Family history of established disease, state what: …………………………………………………………………
Smoking Status (please circle) Non-smoker Ex-smoker Current smoker
If you are a current smoker, please state daily quantity: ……………………………………………………….
We can offer advice and support to help you quit smoking. We have regular stop smoking clinics run by specialist clinicians who will advise you along the way. We can also prescribe nicotine replacement therapy and suggest additional aids which may be of interest. Please enquire at our reception desk.
If you are taking regular medication and have a repeat prescription slip please bring it to the surgery when you return this form. This will enable us to enter your regular medication onto your electronic medical records. Thank you.
Please tick if you have ever suffered from any of the following conditions:
Asthma
Chronic Obstructive Pulmonary Disease COPD
Chronic Heart Disease
Chronic Kidney Disease
Atrial Fibrillation AF
Hypertension or high blood pressure
Stroke or TIA
Diabetes
Dementia
Mental Health
Cancer
Epilepsy
Learning Disabilities
Rheumatoid Arthritis ( not Osteoarthritis)
CARERS REGISTER:
Are you a carer for someone? Yes/No
Do you have a carer?Yes/No
If yes, Carer’s name: ……………………………………………………………………
Carer’s Telephone number : …………………………………………………………
CONSENT FORM – IF YOU WISH ANOTHER PERSON TO BE ABLE TO DISCUSS YOUR MEDICAL AFFAIRS WITH
PERRANPORTH SURGERY
I,
Name: ………………………………………………………………………………….
Date of birth: …………………………………………………………………………….
Address: …………………………………………………………………………………….
……………………………………………………………………………………..
Give my consent for:
Name: …………………………………………………………………………………………
Address: ......
Contact number: ......
Relationship(i.e.Spouse/Partner/Parent/Careretc) …………………………………….
To receive any confidential NHS-related information about me either by phone or face to face from Perranporth Surgery.
SIGNED: ………………………………………………………..
DATE: …………………………………………………………....
For Office Use: code as XaNwR Consent to share with a specified 3rd party
Alcohol Consumption
FAST / 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 Never (0), Less than monthly (1) or Monthly (2).
Stop here if the answer is 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
This information is required before your registration with the Practice can be finalised:
SUMMARY CARE RECORDS:
A summary care record is an electronic record that can help give you safer, faster care by giving healthcare staff instant access to information about your MEDICINES, ALLERGIES AND MEDICINES WHICH MAKE YOU ILL
I would like to share my Summary Care Record (XaXbY)
I do not wish to share my Summary Care Record (XaXj6)
Signed …………………………………………………………………………………………………
Name …………………………………………………………………………………………………..
Date of birth ………………………………………………………………………………………..
ENHANCED DATA SHARING MODEL:
SystmOne is the clinical computer system used by Perranporth Surgery. Opting into this method of sharing your medical information will allow other services who use this same clinical computer, eg Community Nurses, to access your medical record but only if they have need to do so for your clinical care.
Do you consent to the sharing of data recorded here with any other organisations that may care for you?
YES…………………………………………. NO……………………………………….
Do you consent to the viewing of data by this organization that is recorded at other care services that may care for you and where you have agreed to make the data shareable?
YES…………………………………………. NO………………………………………
Please see our website for further information on data sharing, or take a leaflet from the waiting area. Thank you.
The Perranporth Surgery Dr Peter Merrin
Perranporth Dr Karen Murdoch
Cornwall
TR6 0PS
Telephone: 01872 572255
Fax: 01872 573022
Email:
Website:
New service for patients
You may be aware that all practices are required to provide their patients with a named GP who will have overall responsibility for the care and support that the surgery provides to them.
Dr Peter Merrin will be your named GP.
This does not prevent you from seeing any GP in the practice.
All GP’s have full access to your medical notes.
We are also able to offer a basic health check with our healthcare assistant to patients aged 75 years and older. Please enquire at reception for more details.
PATIENT COPY- DO NOT HAND BACK TO SURGERY
Patient name ………………………………………………………………………………………………
Address ………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Telephone Number.....…………………………………………………………………………………
DOB ………………….………………………………………………………………………………………..
NHS Number ………………………………………………………………………………………………
I am the patient named above/carerof the patient named above. Nomination has beenexplained to me andI have also been offered a leaflet that explains nomination.
Name and address of nominated dispenser:
Patient Signature……………………………………………………………………………………………………
Date………………………………………………………………….…………………………….