WELCOME TO
THE FRIARSGATE PRACTICE
Medical notes can take some time to come through from your previous GP practice. To help us with your continuity of care, please take a few minutes to complete this questionnaire.
Full Name: Date of Birth:
Address:
Home Telephone Number:
Mobile Telephone Number:
E-Mail:
What is your marital status? –Single / Married / Divorced / Separated / Widowed
Do you have children 16 years or under who are registered or registering with The Friarsgate Practice?
Child’s Name(s) / Date of Birth / AddressAre you a full time carer for a dependant person? Yes No If yes, please give details
Do you have a carer? Yes No If yes, please give details.
Have you any sort of disability? Yes No
Hearing loss
Visual Loss
Learning Disability
Details of disability –
Do you have any communication needs?
If so do you require any of the following
Large Print
Braille
Easy Read
Email
BSL Interpreter
Please state your ethnic origin–
British/Mixed British Irish Other white background
White and black Caribbean White and black African Caribbean African White and Asian
Indian/British Indian Pakistani/British Pakistani Bangladeshi /British Bangladeshi Chinese
Other Asian background Other black background Other mixed background Other ethnic group
I decline to answer
First Spoken Language:______
ALLERGIES
Please list any Drug/Non Drug allergies you may have
MEDICINES
If you are on any repeat medications, please bring a previous repeat prescription slip and hand to a receptionist, if there are any problems the reception team will contact you. Alternatively please make an appointment to see your GP before you run out.
Please nominate a chemist for your Prescriptions to go toelectronically.
All further prescriptions will go to your specified choice unless we are informed of any change.
Boots UK (Weeke)Lloyds Pharmacy (St Paul’s Surgery)
Boots UK (High Street)Sainsburys In Store Pharmacy (Badger Farm)
Lloyds Pharmacy (High Street)Springvale Pharmacy (Kings Worthy)
Lloyds Pharmacy (Silver Hill)Tesco In Store Pharmacy (Winnall)
MEDICAL HISTORY
Do you or any close family members have any of the following illnesses or conditions?
(Please indicate who in the boxes)
Diabetes / High blood pressureHeart attack / Stroke
Glaucoma / Cancer
Epilepsy / Thyroid disease
PERSONAL DETAILS AND LIFESTYLE
Height:Weight:
I am a Smoker/Non-smoker/Ex-smoker
Exercise: Rarely/Occasionally/regularly
WOMEN ONLY
If appropriate, when did you last have a cervical smear?
Date: Result:
Have you ever had a mammogram?
Date: Result:
ALCOHOL CONSUMPTION
This is one unit of alcohol…
…and each of these is more than one unit
AUDIT – C
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly
or less / 2 - 4 times per month / 2 - 3 times per week / 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? / 1 -2 / 3 - 4 / 5 - 6 / 7 - 9 / 10+
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
Scoring:
A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.
If your total is 5 or more, Please complete the following questionnaire.
Remaining AUDIT questions
Questions / Scoring system / Your score0 / 1 / 2 / 3 / 4
How often during the last year have you found that you were not able to stop drinking once you had started? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
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 needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after 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
Have you or somebody else been injured as a result of your drinking? / No / Yes, but not in the last year / Yes, during the last year
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: 0 – 7 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence
TOTAL Score equals
AUDIT C Score (above) +
Score of remaining questions
Data sharing Opt out form
Please complete the information below.
For details and information regarding these schemes please see overleaf
Full Name:
Date of Birth:
Address:
Text/Voice Text Messages
If you wish for the practice to contact you via SMS then please tick the box:
If you DO NOT wish for the practice to contact via SMS then please tick this box:
Patient Participation Group (PPG)
If you would like to join our PPG please tick the box below.
Patient Participation Group
(You will need to have provided your email address)
Summary Care Record
I do not wish to have a Summary Care Record
Care.data
I do not wish data about me to leave the practice
I do not wish data about me to be shared by HSCIC
Hampshire Health Record
If you do not want to have your information shared, you will need to complete a short form and send it directly to the Hampshire Health Record Operational Team with proof of identity and place of residence For more information and the form please visit,
Patient signature Date
Signature on behalf of a Patient
Relationship to patient
Please note any patient over 16 must complete their own form.
TextMessages
The practice will send SMS text messagesto your phone number in order to notify you of appointments.On occasion we may also send messagessuchas, changes to your booked appointment, national issues such as flu pandemics or the practice being closed due to unforeseen circumstances, etc.
Patient Participation Group (PPG)
The Friarsgate Practice has a PPG that is run by a Steering Group of volunteer patients in partnership with the practice. The purpose of the PPG is to provide a voice for our patients, working constructively with the Practice to help identify patient needs, seeking solutions and contributing to an improvement of service. The Steering Group meet regularly with the practice and provide a channel for communication and information between the Practice and our wider patient group. Joining the PPG means that your email address will be added to the main PPG distribution mailing list and you will receive a welcome email with further information. You can then choose simply to remain on the email distribution list allowing the PPG to communicate with youkeeping you informed and involved with practice information, or you can volunteer to be actively involved in various projects organized by the PPG. We are keen to increase our PPG membership and would encourage and welcome new patients to become members.
Summary Care Record
TheSummary Care Record is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.
Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency or when your GP practice is closed.For more information, please visit
Care.data
Under the new Health and Social Care Act, GP practices arerequired to supply data to the Health and Social Care Information Centre. This differs from the information provided to form a Summary Care Record and is sent to the Health and Social Care Information Centre (HSCIC) and will be used to plan and improve services for all patients.
Your date of birth, full postcode, NHS number and gender rather than your name will be used to link your records in this secure system. Once this information has been linked, a new record will be created. This record will not contain information that identifies you. The type of information shared, and how it is shared is controlled by law and strict confidentiality rulesFor more information, please visit
Hampshire Health Record
HHR is a local combined electronic health record. It brings together information in your health records from different parts of the NHS in Hampshire. The HHR creates a health record about you, which can be accessed by Out of Hours, GP’s, A&E clinical staff, and admissions pharmacists. Any health care professional who wants to look at your recordmust have your permission each time they look at it, unless you are so ill that you are not able to be asked. For more information, please visit