Your Old Medical Records Will Take a Few Weeks to Arrive from Your Previous Doctor So Please

Reviewed by ST April 2014

CHELMER VILLAGE SURGERY - NEW PATIENT HEALTH QUESTIONNAIRE

Your up-to-date medical records will take a few weeks to arrive from your previous doctor so please complete the form as best you can to help us look after you in the meantime. You will need to provide one of the following regulated forms of identification, Driving Licence/Passport/Utility Bill/Bank Statement, etc., showing your new address, this will avoid a delay in your registration.Please circle/tick where appropriate.

Surname: / First names:
Previous surname: / N.H.S. No:
Date of birth: / Post code: / Contact telephone number:
Home
Mobile
Address: / Sex:
Male 
Female  / Your occupation:
Are you a carer for someone else who is also a patient at the surgery (other than your children)?
If YES, for whom? / Yes / No / Are you cared for by someone else?
If YES, who?
their contact telephone number: / Yes / No
If you are over 15 years old please record: / Your height / Your weight / Your waist measurement

Are you interested in obtaining help from the surgery to lose weight? Yes / No

Smoking:

Never smoked
I currently smoke (on average) ______cigarettes per day, or ______oz. of tobacco per week.
I am an ex-smoker. I gave up in ______(year).
If you are currently a smoker but are considering stopping, an information leaflet is available at reception for advice and tips on stopping smoking.
If you smoke and would like help giving up please phone the NHS Quit line on 0800 00 22 00
For ladies aged 25 to 65 the date of your last cervical smear: / normal or
abnormal? / For ladies aged 50 to 70 the date of your last mammogram: / normal or
abnormal?
If you DO NOT want a smear test please sign here:
(however we are required to re-invite you in 5 years time)
For ladies have you had a hysterectomy and were your ovaries removed too?
If so when: / Hysterectomy?
Yes / No / Ovaries removed?
Yes / No / Don’t know
For everybody, have you had your spleen removed? / Yes / No / When?
FLU vaccinations - if you are 65 or over, living in a residential home, adult or child of any age with any of the following conditions; heart disease, angina, heart failure, respiratory disease, asthma, bronchitis, cystic fibrosis or emphysema, kidney disease or diabetes then you are entitled to an annual flu jab. / However if you DO NOT want a flu jab please sign here:
About your own health, do you suffer from or have you had any of the following conditions:
Serious depression or anxiety Heart attack (MI) Under active thyroid Stroke Heart failure
Epilepsy High blood pressure Asthma Learning disability Diabetes Angina
Chronic Bronchitis (COPD)  Dementia Atrial fibrillation Kidney failure Cancer
Serious family illness, have any of your close family had any of the following and if so who and at what
age?
Heart attack (MI) under the age of 50? Yes / No
Cancer Yes / No
Diabetes Yes / No
Serious depression or anxiety Yes / No
Other/s (please list)
Are you aware of any known family illnesses? / Allergies: Are you allergic to anything? / Level of exercise:
Inactive
Moderate Vigorous  / Diet:
Good
Moderate Poor

Alcohol:

Please answer the following 3 questions. Circle the answer that best describes your drinking habits.

The Government wishes us to record your ethnic background, please tick the background closest to your own:
British or mixed British background  Other White background Indian or British Indian background 
Other mixed background Ethnicity not stated Other ethnic group (please state) 
Black or mixed Black background 
Language:Is English your first language Yes / No / If No, please give details
Please list any previous vaccinations you have been given:
Name of vaccination / Date given / Name of vaccination / Date given
When was your last tetanus jab?
Please list any other medical conditions and for ladies any pregnancies with the date of birth, birth weight and sex of your children:
Please continue on the blank page overleaf if you require more space.
MEDICINES, DRUGS AND TREATMENT:
Are you on any regular tablets or medications including the contraceptive pill? Yes / No
If YES, please make an appointment with the nurse as soon as you can – until you havebeen seen we cannot give you any more of your tablets or medicines – please bring all your tablets and medicines with you so the nurse can see exactly what you are taking or alternatively, bring a copy of your repeat prescription request slip from your previous surgery.
SUMMARY CARE RECORD (SCR)
Attached to this form is an information leaflet regarding the Summary Care Record. Please read this information.
If you wish to opt out of the Summary Care Record, please ask our receptionist for an Opt OutForm.
Care.Data Opt Out – Information leaflets available in the waiting room
NB: This is different from the Summary Care Record
Individuals have the right to object to the disclosure of Personal Confidential Data (PCD) and can inform their GP of their wish to object. On completion of this form we will add a Read Code to your medical records to prevent your PCD leaving this GP practice apart from in certain (very rare) circumstances when your objection can be overridden by specific legal requirements.
I wish to implement my constitutional right to object to the disclosure of my PCD from Chelmer Village Surgery to the Health and Social Care Information Centre.
Name: ……………………………………… DOB: ……………………………………
Address:...... …………………………………………………………..
……………………………………………………………………………………………
Date: ……………… Signature: ………………………………………………………

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