THE VILLAGE SURGERY NEW PATIENT QUESTIONNAIRE
Name: ……………………………….………..………… Date of Birth: …………………….……….…..
Address: …………………………………………………………………………………………..………….
Post Code: ………………………… e-mail Address: ……………………………………………………
Telephone No. ……………………………………….… Mobile No. ……………..……………...….....
We will text appointment reminders and surgery information to your mobile unless requested not to do so
Occupation: ………………………………..………….. Marital Status: …………………………....….
Are you a carer for the elderly or anyone with a physical or mental disability registered at this Practice? Yes/No
If YES please give name: ………………………………………………
Ethnic Group: …………………………..………….….. Language: ……………………………………
Important past medical problems, including operations with dates:-
……………………………………………………………………………………………………………......
Current medical problems:-
……………………………………………………………………………………..…………………………...
Do you have any information or communication needs? If Yes, please provide details
Current Medication: …………………………………………………………………………………………
Prescriptions can be sent electronically to a nominated chemist – please state which chemist you wish prescriptions to be sent to:
Allergies, especially to drugs: ………………………………………………………………………..…….
Are there any illnesses which may be hereditary in your family? ………………………………………
Please tick ONE of the following:-
Never smoked tobacco Stopped Smoking Current smoker
If you are a current smoker and would like smoking cessation advice please make an appointment with Hertfordshire Stop Smoking on Freephone:: 0800 389 3998 or 0800 1690 169
What is your Height: ………………………….…………… Weight: …………………….……………
Do you have or think you may have a learning disability? Yes/No
Any other information you think we should be aware of? ……………………………………………….
…………………………………………………………………………………………………………………..
Have you been registered with this Surgery previously? Yes/No
FOR WOMEN ONLY
Please give details of any pregnancies with dates:-
……………………………………………………………………………………………………………......
When was your last cervical smear? ……….……… Any previous abnormal smears? …………….
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Photo ID and proof of address seen Yes/No Initials Date
This is one unit of alcohol…
…and each of these is more than one unit
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
Scoring:
If score is 0, 1 or 2 on the first question
continue with the next three questions
If score is 3 or 4 on the first question – stop here.
An overall total score of 3 or more is FAST positive.
What to do next?
If FAST positive, complete remaining AUDIT questions (this may include the three remaining questions above as well as the six questions on the second page) to obtain a full AUDIT score.
Score from FAST (other side)
Remaining AUDIT questions
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 - 8 / 10+
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 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
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
TOTAL AUDIT Score (all 10 questions completed):
0 – 7 Lower risk,
8 – 15 Increasing risk,
16 – 19 Higher risk,
20+ Possible dependence
Patient Access Application Form
Patient to complete:
Name:D.O.B:
Address:
Telephone No:
Mobile No
Verify
Email address (must be patients own email)
Verify
Practice guidance received / YES / NO (Delete as appropriate)
Please state the pharmacy you wish your prescriptions to be sent to
I am the patient (over 14 years old) Signed…………………………………………………….
I am the parent/guardian for patient if under 13
I have collected my Patient Access form from The Village Surgery
Please email my Patient Access form to the verified email address on this form
PLEASE REMEMBER THAT ID WILL BE REQUIRED FOR ALL PATIENTS OVER THE AGE OF 14
Receptionist to complete
Identification seen …………………………………………… Seen by ………………………………….. Date………………………………
Consent for Summary Care Record with Additional Information
The Summary Care Record (SCR) is a brief snapshot of your GP medical record which holds details of the medication you are on, allergies you may have and details of any adverse reactions you have experienced. With your permission, the practice can add essential details about your healthcare which can be very difficult to remember, particularly when you are unwell. Having Additional Information in your Summary Care Record means that, when you need healthcare, you will be helped to recall these vital details.
The Summary Care Record with Additional Information can be used by other NHS organisations, such as A&E and Out of Hours. These organisations can only access this information with your permission and with the appropriate rights. There may be occasional circumstances where a clinician is unable to consult you. For example, if you are unconscious, healthcare staff may look at your record without asking you. An audit trail is kept to identify who has viewed your record, where and when.
For more information, please read the leaflet given with this form.
If you are happy for your doctor to allow Additional Information to be added to your Summary Care Record, please read the statement below and sign where requested:
I consent for medication, allergies and adverse reactions and additional information to be made available to other healthcare providers. This may include information detailing any health issues which my GP and I consider to be important to my wellbeing. I can change my mind at any time by notifying my practice.
Name:
Signature:
Date of Birth
Note to practice – Please ensure that this information is added to the above patient’s record.
Processed by: Date:
NEW PATIENT INFORMATION
ONLINE SERVICES
Patients can book appointments and order repeat prescriptions online using the patient access system.
Once you have registered with the surgery you can request your patient access log in details. Please collect this information from the surgery one week after requesting.
PATIENT PARTNER – AUTOMATED TELEPHONE APPOINTMENT BOOKING SERVICE
Patients can call the Surgery on 01582 763951 anytime day or night to
Book, cancel or amend appointments
Appointments can be booked with
1. Usual GP if an appointment is available within two weeks
2. If no appointment available with usual GP within two weeks- patients can book next appointment available with another GP
3. Blood tests at Harpenden Memorial Hospital
ELECTRONIC PRESCRIBING SYSTEM
EPSis a fantastic new system that allowsusto send yourprescriptions electronically to apharmacy ofyour choice.This makes the process more efficient andpatients can collect their prescriptions from the pharmacy.Please inform reception which pharmacy you would like your prescriptions to be sent to.
What to do if the surgery is closed
Call the NHS 111 Service 365 days 24 hours per day
Calls are free from landlines and mobiles – put 111 in your mobile!
For urgent attention outside of normal surgery hours please call Herts Urgent Care - telephone number111.
NHS Walk-In Centres 365 days
If the surgery is closed and you need to see a GP or a practice nurse urgently you can attend a NHS Walk-In Centres (WICs), where you can see a nurse/GP without an appointment.
They offer advice, assessment and treatment for minor ailments and injuries. Please note, WICs are not designed for treating long-term conditions or immediately life-threatening problems.
Your nearest NHS Walk-In Centres are:
West Herts Medical Centre Hemel Hempstead Hospital telephone 03000 33 22 33
http://www.westhertsmedicalcentre.nhs.uk/
All children under 5 are assessed and observations taken upon arrival.Luton Town Centre 14-16 Chapel Street, Luton LU1 2SE Telephone 01582 709290 http://www.towncentresurgeryluton.nhs.uk/walk-in-centre,42796.htm
Urgent Care Centres
The Urgent Care Centre is open 24 hours a day, every day of the year, to treat adults and children of all ages with minor injuries or minor illnesses. No appointment is necessary. X-rays can be carried out at the Centres - although not 24 hours.
Urgent Care Centres can treat:
· Muscle and joint injuries, such as strains, sprains, sudden back or neck pain, tendonitis and soft tissue injuries
· Suspected fractures and broken bones
· Bites, stings, cuts, bruises and grazes
· Burns and scalds
· Foreign bodies that are stuck in ears or noses
· Minor eye injuries
· Minor head injuries
· Minor illnesses which would normally be treated by a GP, but which can’t wait until your GP practice is next open
Urgent Care Centre - Hemel Hempstead Hospital, Ground Floor Jubilee Wing http://www.hertsurgentcare.com/
Urgent care Centre QE2 Hospital Welwyn Garden City http://www.newqeii.info/services/urgent-care-centre
Out-of-hours services are generally busy so please think carefully before asking to see a doctor and only do so if you genuinely cannot wait until the surgery re-opens.
In a genuine emergency you should call 999. Chest pains and / or shortness of breath constitute an emergency. Useful websites: www. patient.co.uk
www.nhs.uk/Conditions/pregnancy-and-baby/pages/coughs-colds-ear-infections.aspx
The Village Surgery Practice Guidance for Patient Access
to book and cancel appointments,
order repeat prescriptions, check immunisations.
Before you begin to use EMIS Access we would appreciate it if you could read the following guidance regarding the booking of appointments and ordering repeat prescriptions over the Internet.
Please keep this page of the document for your own reference.
Reasons for Appointment
You may wish to enter a reason for your appointment in the box provided when booking an appointment but this is not compulsory. Please be assured that all details entered are secure and cannot be intercepted but can be viewed by our reception team. Our practice has a strict confidentiality policy for all staff.
Missed Appointments
Please let us know if you will be unable to attend an appointment that you have booked, you can cancel appointments on line. This will allow us to offer the appointment to another patient.
Appointments
Due to the nature of nurses’ appointments we are unable to offer them online at this time. However, we hope to be able to offer this service in the future.
Repeat Prescription Requests
You can order your own repeat prescriptions on line via the Patient Access facility. Once you have registered for Patient Access and you have logged into the website it will offer you the option of booking an appointment or requesting a repeat prescription. PLEASE NOTE: you can only request medication that has been set as a repeat prescription. If you have been issued with medication by your GP to try or on a one-off or acute basis, you will need to contact your GP to discuss whether it can now be changed to a repeat. Until it has been changed in your medical records it will not show up on the Patient Access website.
Inappropriate use
We monitor the use of this service and we are sure that you will find it useful. However, if we find any abuse of the service, we will revoke your access to the service and you will have to liaise with our reception team for services. We would consider inappropriate use as: sending inappropriate or abusive messages, booking appointments and not using them more than 3 times a year, booking appointments for other family members using your own name.
Your Responsibility
The practice will take every measure to ensure that your Patient Access application is secure. It is your responsibility to ensure that your Patient Access account remains this way. You are able to terminate or reset your Patient Access Account at any time by contacting the surgery in writing. You may wish to do this if you think someone else knows your log in details or if you have shared details with a family member or partner and no longer wish them to know these details.
What to do next?
If you would like to register for Patient Access please complete the attached Application Form and return it to the surgery in person. Anybody over the age of 16 will need to provide identification, a passport or driving licence is ideal. You will then be able to create a new account on the Patient Access website.
When patients turn 14 their account will be deactivated and they will need to complete their own Patient Access form and provide ID.