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Two Rivers Medical Centre – New Patient Questionnaire

To be completed by the person applying to register or their parent/guardian.

If you have internet access, please ask a member of our Reception Team about.

Please complete both sides of this form in BLOCK CAPITALS

Title:Mr / Mrs / Miss / Ms / Dr / Other (please state )
Last or Family Name:First Name(s):
Date of Birth:Occupation:
Address:
Postcode:
Telephone numbers – Daytime:Evening:Mobile:
Are you happy to receive text messages from us? (appointment reminders etc) Yes No
First spoken Language: Decline Yes
(If applicable state “English” or seeseparate sheet. You can decline to answer)
Ethnic Origin: Decline Yes
Please give details of your Ethnic origin using the attached list as a guide.
(This information is considered helpful in providing appropriate individual care but you can decline to answer)
Are you housebound?Yes No  / Are you a Carer?Yes No 
Do you have a Carer? If yes, please give a name and telephone number
Name, address and contact telephone number of Next of Kin: (Please state whether parent/son/daughter etc)
Do you suffer from any of the following? Or does an immediate family member where indicated?
Conditions / You / Family(tick only if a parent/son/daughter/brother/sister)
Asthma or COPD / YesNo
Cancer / YesNo / YesNo
Diabetes / YesNo / YesNo
Thyroid problems / YesNo
Stroke / YesNo / YesNo
Angina/Heart Attack / YesNo / YesNo
Blood Pressure / YesNo
Kidney Problems / YesNo
Have you received treatment for depression? / YesNo
Do you smoke? / YesEx-smokerNever
Alcohol Consumption – complete if aged 16 and over otherwise continue overleaf
(Please see separate list for definition of units) / Scoring System / Score
0 / 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 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
If total is 5 and over please ask reception for separate questionnaire Total
Please tick if you do not wish to complete

Please continue overleaf
Page 2

If you are aged 16 and over, please weigh yourself and check your height on the scales provided and calculate your BMI(see separate instructions) or ask Receptionist to calculate.
Height: / Weight: / BMI:
Women’s Health
Are you pregnant? / YesNo
Have you had a hysterectomy? / YesNo / If yes, when?
Allergies
Do you have an allergic reaction
e.g. rash/collapse, to any medication and/or eggs? / YesNo / If yes, please specify
Please attach a printed list of repeat medication from your previous surgery or list below. State “NONE” if you are not on any repeated medication.
NAME of Medication
(also state in what form e.g.
tablets/capsules/liquid/inhaler) / DOSE?
i.e. one a day / 2 puffs four times a day. / What complaint is it taken for?

To ensure that we include patients in all relevant Health Care Programmes you will be asked to have a 20 minute registration appointment with a clinician if you are:

  • Male aged 35 and over, Female aged 40 and over.
  • You are aged 16 or over and have a BMI of 30 or over.
  • You have indicated a medical condition where a review with a clinician will be beneficial.
  • You are female and aged 25 and over and are registering for the first time in the U.K.
  • You are aged 5 and under and are registering for the first time in the U.K.

Alternatively –

  • You are welcome to ask Reception for a registration appointment.

Please bring a urine sample to the registration appointment. Containers are available from Reception.

If you are asked, or wish to attend a registration appointment this must be completed within 2 months. Please inform us if you are unable to keep a registration appointment once booked. Registered patients are advised that if they fail to attend, without reason, two or more pre-booked appointments with a clinician, they may be asked to register at another Medical Centre.

Please return the completed form to Reception with your medical card (if available)

Patient signature...... Date......

or the signature of Parent/Guardian if on behalf of patient

Summary Care Record – In the event of an emergency details of any current prescriptions, allergies or bad reactions to medicines will be made available to health professionals throughout the U.K. If you do not want this information shared, please tick the box 

OFFICE USE ONLY

Emis access Yes Appointment declined Yes

If an appointment was made, please complete the following:-
Appointment with:- / Date of Appointment:- / Time of Appointment:-
Staff Name:-

Electronic Sharing

Electronic Data Sharing Module (eDSM)

Many organisations in the NHS use a secure computer system called SystmOne to hold your records. With your consent, it allows the healthcare professionals who care for you to share your medical information with each other to make sure you receive the best possible care.

Imagine you are receiving care from three different care services; your GP, a district nurse and a skin specialist.

Sharing Out
controls whether your records here can be shared with other care services while you are being treated there.
Your decision (please tick one):Yes (shared) or No (not shared)
93.80% of patients with a decision in Suffolk have chosen ‘Yes’ to share out their GP record to their other care providers*
Sharing In controls whether this health service can view information recorded by other services where you have received treatment there.
Your decision (tick one):Yes (shared) or No (not shared)
95.94% of patients with a decision in Suffolk have chosen ‘Yes’ to allow their GP to view records from other care providers*

GP SurgeryTwo Rivers Medical Centre

Patient Name (Print Name)

Date of Birth

Patient Signature………………………………… Date ……/……/201…

Summary Care Record

The NHS in England has introduced the Summary Care Record, an electronic health record that can be accessed when you need urgent treatment from somebody other than your own GP.

Summary Care Records contain key information about the medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had in the past. You will be able to add other information too if you and your GP agree that it is a good idea to do so.

If you have an accident or fall ill, the people caring for you in places like accident and emergency departments and GP out of hours services will be better equipped to treat you if they have this information. Your Summary Care Record will be available to authorised healthcare staff whenever and wherever you need treatment in England, and they will ask your permission before they look at it.

You are free to change your decision at any time by informing your GP practice.

Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, please tell them about Summary Care Records and explain the options available to them.

For more information call the Health and Social Care Information Centre on 0300 303 5678.

Please Indicate your Choice below:

I DO want my medications, allergies and adverse reactions to be released by my GP surgery for the summary care record

I DO NOT want my medications, allergies and adverse reactions to be released by my GP surgery for the summary care record

H:\Central Storage\Reception Master Copies\Registration + Refusal forms\NEW PATIENT QUESTIONNAIRE 2016.rtf