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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.
- 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.
- 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.
- 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
DiabetesNoYes………
AnginaNoYes………
Heart attackNoYes………
or StrokeNoYes………
CancerNoYes………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
DiabetesNoYes……………………………………
AnginaNoYes……………………………………
Heart attackNoYes……………………………………
or StrokeNoYes……………………………………
CancerNoYes………………… 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 / BoosterDTaP/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? YesNo
Do you have a carer?YesNo
Do you consent to us passing on your information to Cheshire Carers YesNo
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 smokerNever smokedEx 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?YesNo
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?YesNo
(for instance a sign language interpreter)
Do you use a hearing aid or communication tool?YesNo
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 Score0 / 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)