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Dear Patient

WELCOME TO PARK MEDICAL CENTRE We are pleased you wish to register with us.

In order to complete the registration process, you will need to complete a registration form and medical questionnaire. You will also need to let us have proof of your identity.

  1. Registration Form: You should fully complete the form, including your own details, those of your previous doctor and the section about organ donation on the rear of the form. When completed please remember to sign the form before returning it to us.
  2. Patient Questionnaire: Please complete the questionnaire to inform your doctor of any medical problems that you may have and ensure that we are able to give you continuity of treatment until we receive your medical records from your last practice.
  3. Proof of identity: We cannot process your application to register, without proof of your identity. You will need to let us have two forms of identification; acceptable documents are listed on the next page.

Our practice leaflet gives full details of our opening times and the services we offer. Alternatively, these details are available on our website:

If you require any further information in respect of any of the services offered by the practice, please do not hesitate to ask at reception.

Yours sincerely

Dr Christopher R Lewis

Dr Neil S Blacklock

Dr Claire E Schofield

Dr Yvette Brindle

Dr Roland Potocki

Dr. C. R Lewis, Dr. N. S. Blacklock, Dr C E Schofield Dr Y Brindle, Dr R Potocki

PROOF OF IDENTITY REQUIRED FOR REGISTRATION PURPOSES

Patients should produce ONE document from EACH list

(please tick to indicate the documentation you are using)

Proof of Identity
(One document from this column) / Tick if used / Proof of Address
(One document from this column) / Tick if used
Current signed UK/EEA/EU passport / Current signed full UK/EU driving licence (if not used as proof of identity) (photo-card only is not acceptable for this purpose)
Current signed passport (non UK/EEA/EU) with valid Visa / Bank, building society, or credit card statement (if under 3 months old). NB we do not accept statements printed off the internet
Current signed full UK/EU driving licence (photo-card or paper style) / Mortgage statement (under 12 months old)
EU/EEA National Identity card / Current state pension or benefits documentation or notification from the Dept. of Work & Pensions, confirming right to benefits (if not used as proof of identity)
Current firearms certificate / Current local council rent card or tenancy agreement
Current state pension or benefits documentation or notification from the Dept of Work and Pensions, confirming right to benefits / Utility bill, utility statement or letter from supplier of utilities, dated within the last 3 months
Blue disabled drivers pass / Local authority tax bill/council tax bill for current year
UK birth certificate and marriage certificate where name has changed on marriage / Official letters from a care or nursing home confirming residence
Solicitors’ letter, confirming completion of house purchase or land registration (if in last 6 months) together with proof of previous address
For under 18s living at home
Birth certificate
Provisional photo-card driving licence

For Practice use only:

Advised patient their Registered GP will be…………………………………. (67DJ)

Proof of ID seen:Details (inc passport etc number)

Proof of Address seen:Details (including driving licence etc number)

Member of staff signature: ………………………………………………Date: …….. / …….. / ……..

Park Medical Centre

PATIENT QUESTIONNAIRE - CONFIDENTIAL

Full Name ______Mr/Mrs/Miss/Ms ______Date of Birth __ __ / __ _/ __

d d m m y y y y

Occupation ______First Language ______

Have you previously been a patient of Park Medical Centre? Yes / No Year left practice ……………….

Medical History:

Please tell us, below, about any ongoing medical problems. Have you ever suffered from any of the following?

Age at onset

DiabetesNoYes………

AnginaNoYes………

Heart attackNoYes………

or StrokeNoYes………

CancerNoYes………Type of cancer ………………………………

Other illness/condition (Please give details) ………………………………………………………………………………….

Family History of Disease

Have any of your IMMEDIATE family (mother, father, sister, brother) been diagnosed with any of the following medical conditions? Relationship of Age at Onset

relative to you

DiabetesNoYes……………………………………

AnginaNoYes……………………………………

Heart attackNoYes……………………………………

or StrokeNoYes……………………………………

CancerNoYes………………… Type of cancer…………………………

Medication:

Please list all current medication, including dose and frequency. If possible please hand in the white repeat slip from your previous Doctor.

Allergies:

Please list any allergies you have to drugs or other substances e.g. Penicillin

Women:

Date of Last Cervical Smear Test …………………….

Any abnormalities notified (give details if known) …………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

Please give dates of any Live or Still Births (year will suffice). ………………………………………………………………

Immunisations – AdultsPlease tick to show the immunisations you’ve had and the year given (if known)

Immunised (tick) / Not Immunised (tick) / Year immunisation received (if known)
Tetanus Booster
Measles
Shingles Booster
Influenza
Pneumonia

Immunisations – Childhood: We need details for those aged 5 and under with year

Date of Vaccination / 1st / 2nd / 3rd / Booster
DTaP/IPV/HIB (diptheria, tetanus, whooping cough, Hib)
Penumoccocal
Meningitis C
MMR (Measles, Mumps, Rubella)
Rotavirus
Meningitis B

Carer: Do you act as a carer for any other person? YesNo

Do you have a carer?YesNo

Do you consent to us passing on your information to Cheshire Carers YesNo 

If so: please give name &,address of the person you act as a carer for or who acts as a carer for you:

…………………………………………………...... ……………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

Relationship to you: i.e relative (son, daughter etc or neighbour) ……………………………………

Smoking (Please indicate your current smoking status by ticking the relevant boxes):

Current smokerNever smokedEx smoker 

Current / ex smokers only:Number per day…………………

Ex smokers:When did you give up? …………………

If you would like to know about local resources to help you stop smoking please indicate here 

Do you have any special Communication Needs?YesNo

If “Yes”:

Do you require information in special format?Braille

Large print

Easy read

Do you wish to receive communications in a particular way?Text

Email

Do you need someone to support you during appointments?YesNo

(for instance a sign language interpreter)

Do you use a hearing aid or communication tool?YesNo

EMAIL ADDRESS

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Alcohol:

Using the list below, please indicate how many standard units of alcohol you drink per week ………… units

Pint of regular beer / lager / cider2 units

Alcopop or can of lager1.5 units

Regular (175ml) glass of wine2 units

Single (pub) measure of spirits1 unit

Bottle of wine9 units

FAST Alcohol Screening Test (FAST). During the last 12 months

Questions / Scoring System / Your Score
0 / 1 / 2 / 3 / 4
Question 1: How often do you have 8 (men) / 6(women) or more drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Only answer the following questions if your answer to Question 1 is monthly or less
Question 2: How often in the last year have you not been able to remember what happened when drinking the night before? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Question 3: How often in the last year have you failed to do what was expected of you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Question 4: Has a relative / friend / doctor / health-worker been concerned about your drinking or advised you to cut down? / No / Yes, but not in the last year / Yes, during the last year

Scoring: A total of 3+ indicates hazardous or harmful drinking

PATIENT ETHNIC ORIGIN DETAILS
This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.

Please indicate your ethnic origin. This is not compulsory, but may help with the early identification of some of conditions, which are more common in people of certain ethnic groups.

Choose ONE section below and then tick ONE box to indicate your background.
Name...... Date of Birth …….. / …….. / ………
WhiteBritish 

Irish

Any other white background, please specify:______

MixedWhite and Black Caribbean 

White and Black African 

White and Asian 

Any other mixed background, please specify:______

Asian/Asian BritishIndian 

Pakistani 

Bangladeshi 

Any other Asian background, please specify:______

Black/Black BritishCaribbean 
African :

Any other black background, please specify______

Chinese 

Other ethnic group (please specify)

I decline to give this information

______

Patient Summary Care Record: The NHS in England is introducing Summary Care Records to improve the safety and quality of patient care. This will allow healthcare staff to access important medical (such as any allergies you have or medication you’re taking) if they need to treat you, for example in an emergency. Please sign below to indicate whether or not you agree to sharing of your summary care record. See NHS Choices website for more details.

I DO / DO NOT agree to sharing of my healthcare information on a national level

I DO / DO NOT agree to sharing of my healthcare information locally ____________

PATIENT CHECKLISTBefore handing these forms in at reception please check that you have: (Tick)

Brought 2 official documents, one proving your identity, the other your address (see page 2)

Identity

Address

Completed and signed the NHS Family doctor services registration form

Completed the patient questionnaire (all sections)