THE SURGERY Dr Zaw Thike MBBS DFFP MRCGP DRCOG

Dr Julie Marshall MBCHB DFFP DRCOG

PRIVATE AND CONFIDENTIAL

NEW PATIENT REGISTRATION QUESTIONNAIRE

To be completed for patients over 16

THE SURGERY

CHURCH ROAD

LYMINGE

FOLKESTONE

CT18 8HY

Telephone: 01303 862109

Fax: 01303 863643

______

BRANCH SURGERY

99 CANTERBURY ROAD

HAWKINGE

KENT

CT18 7BS

Telephone: 01303 893381

Fax: 01303 893381

Email:

______

A very warm welcome to our small rural dispensing Surgery

Please kindly complete this questionnaire along with the fully completed GMS1 registration form so we can input your information onto our clinical system.

Please refer to the surgery booklet in relation to information within the questionnaire as well as other relevant information you may find useful.

Please note that there we offer appointments at both Lyminge and Hawkinge, and you may be required to travel to either site for an appointment.

Should you require any further information or assistance then please do not hesitate in speaking to a member of the reception team or the Practice Manager

PLEASE BRING BACK TO THE SURGERY – DO NOT POST IT

Updated November 2015

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PRIVATE AND CONFIDENTIAL

Personal Information

Title: / Forename: / Surname:
Occupation: / Date of Birth: / NHS Number:
Address:
Postcode:
Telephone Number: / Mobile Number:
Email Address:
Ethnicity
First Language

Do you suffer from any of the following illnesses? - Please detail date diagnosed

Angina / Asthma / Atrial Fibrillation
COPD / Depression / Diabetes
Dyspepsia (Indigestion) / Epilepsy / High Blood Pressure
Heart Failure / Stroke / Thyroid Disease
Myocardial Infarction (Heart Attack) / Chronic Heart Disease / Chronic Kidney Disease

Any other illnesses (please give details) ______

Do you have any allergies?
If yes please state what they are: / YES / NO

Family History

Have any family members (mother, father, uncle, aunt, grandparents, nieces, nephews, brothers, sisters) ever suffered from any serious illness?

(Diabetes, Heart Disease, High Blood Pressure, Glaucoma)

Relationship (e.g. Mother) / Date of Birth / Detail Illness

Smoking Status (please circle answer)

Current Smoker / Ex Smoker / Non-Smoker

Drinking Habits (Please circle answers)

1 Drink = ½ pint beer or 1 glass of wine or single spirit

How often do you have a drink containing alcohol?

Never / Monthly or less / 2-4 times a month / 2-3 times a week / 4 or more times a 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+

Men: How often do you have EIGHT or more drinks on one occasion?

Women: How often do you have SIX or more drinks on one occasion?

Never / Less than Monthly / Monthly / Weekly / Daily or almost daily

If you would like to discuss your alcohol intake then please make an appointment with the Practice Nurse

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Are you under the care of a Hospital Specialist / YES / NO
If yes, please give details:

Women Only

If you are using contraception at present then please give method?
When did you have your last smear?
Have you had a hysterectomy? / YES / NO
Have you had a mammogram? / YES / NO

Consent

Prescription
I give consent for prescriptions to be collected on my behalf / YES / NO
Messages
I give consent for the practice to leave messages on my answerphone / YES / NO
Messages with 3rd Party
I give consent for the practice to leave a message with the persons named below about any aspect of my medical treatment / YES / NO
Names: ______
______
Medical Details
I give consent for the practice to disclose results and to discuss any medical treatment or problems with the persons named below: / YES / NO
Names: ______
______
Any consent given will remain in force until further notice or cancellation by me
Patient signature:
Date:
STAFF ONLY – Added to Emis System / Name: / Date:

Summary Care Record

On registering at the surgery patients are automatically given an electronic summary care record. Staff will be permitted to access information, via strict security measures, if they are involved in your treatment. Having a summary care record will help ensure that the right people have the right information at the right time. For example current medication, allergies etc…)

Should you choose not to have a summary care record please complete details below:

I do not wish to have a summary care record / Patient Signature

For children under 16 years agreement will be assumed unless the parent or guardian opts out on their behalf.

GP Data Extraction Service

Confidential information from your medical records can be used by the NHS to improve the services offered so that the best possible care can be provided for everyone. This information along with your postcode and NHS Number but not your name is sent to a secure system to be linked with other NHS services.

Should you choose not to have a summary care record please complete details below:

I do not wish to participate in GP data extraction / Patient Signature

For children under 16 years agreement will be assumed unless the parent or guardian opts out on their behalf.

For more information please visit NHS choices website

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Next of Kin

Name______
Contact Number ______
Relationship to patient______
Is this your emergency contact? YES / NO
STAFF ONLY – Added to Emis System / Name: / Date:

Carer

What is meant by a carer?

A carer is someone wo looks after a relative or friend who needs support because of age, physical or learning disability or illness.

Parent carer - a parent of a disabled child often see themselves as parents rather than carers, however additional services and support may be available

Young carers – This means carers who are under 18. The person receiving care is often a parent, but it could be a brother, sister, grandparent or another relative who needs support.

If you are a carer and would like your name to be added to our register of carers, then please complete the following information:

Are you a Carer? / YES / NO
Name of person being cared for______
Type of disability______
Telephone Number ______
Relationship to carer ______
As the person being cared for we need permission to put your name on the carer register. This information is confidential.
Signature ______Date ______
If the person being cared for is unable to provide a signature then please indicate reason ______
Does someone care for you? / YES / NO
Name of carer ______
Telephone Number ______
Relationship to you ______

Patient Participation Group

Would you like to receive information about our patient participation group via email?
If yes please ensure you have given your email contact above. / YES / NO

New patient questionnaire – 4 page document read and completed

Patient Signature / Date completed

Thank you for your time in completing this questionnaire which will help us until we receive your medical records from your previous GP.

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