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THIS IS AN EXAMPLE OF OUR REGISTRATION DOCUMENT.

 

Please collect a registration form from the surgery and complete with proof of address and ID.

 

Prospect Medical Practice

95 Aylsham Road

Norwich                                                                                              

NR3 2HW.

 

 

New Patient Registration Form - Adult

Please complete all pages in full using block capitals

 

1. Background Details

 

Contact Details

Name

 

Gender

 

Address

 

Date of Birth

 

Home Telephone

 

Work Telephone

 

Mobile Telephone

I consent to be contacted* by SMS on this number:

Email

I consent to be contacted* by email at this address:

Family Registered With Us

 

Marital Status

Single             Married            

         

 * It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. 

   We may contact you with appointment details, test results or health campaigns

   If you do not consent to being contacted by SMS or Email, please tick here:     SMS     Email

 

Other Details

Previous GP

Name:                                               

Address:

 

Country of Birth

 

Ethnicity

 White (UK)

 White (Irish)

 White (Other)

 Black Caribbean

 Black African

 Black Other

 Bangladeshi

 Indian

 Pakistani

 Arabic

 Chinese

 Other

Religion

 C of E

 Catholic

 Other Christian

 Buddhist

 Hindu

 Muslim

 Sikh

 Jewish

 Jehovah’s Witness

 No religion

 Other:

Housing

 Own Home

 Sheltered House

 Residential Home

 Nursing Home

 Housebound

 Homeless

 Refugee

 Asylum Seeker

Employment

 Employed

 Self-employed

 Student

 Unemployed

 House husband

 House wife

 Carer

 Retired

Overseas Visitor

 Yes

 European Health Insurance Card Held

Armed Forces

 Military Veteran

 Family member

 

 

           

 

Communication Needs

Language

What is your main spoken language?

Do you need an interpreter?                         Yes         No

Communication

Do you have any communication needs?     Yes         No  (If Yes please specify below)

 Hearing aid

 Lip reading

 Large print

 Braille

 British Sign Language

 Makaton Sign Language      Guide dog

 

Carer Details

Are you a carer?

 Yes – Informal / Unpaid Carer

 Yes – Occupational / Paid Carer

 No 

Do you have a carer?

 Yes   

Name*:

Tel:

Relationship:

           

* Only add carer’s details if they give their consent to have these details stored on your medical record
 

2. Medical History

 

Medical History

Have you suffered from any of the following conditions?

 Asthma

 COPD

 Epilepsy

 Heart Disease

 Heart Failure

 High Blood Pressure

 Diabetes

 Kidney Disease

 Stroke

 Depression

 Underactive Thyroid

 Cancer- Type:

Any other conditions, operations or hospital admission details:

 

 

 

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

 

 

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

 Asthma………………….

 COPD………………...…

 Epilepsy…………………

 Heart Disease……….…

 Stroke…………….……..

 Blood Pressure…………

 Diabetes………..………

 Kidney Disease..………

 Liver Disease..….……..

 Depression………..……

 Thyroid…………..….…..

 Cancer…………………..

Other:

 

 

Allergies

Please record any allergies or sensitivities below

 

 

Current Medication

Please check and include as much information about your current medication below

Please give us your previous repeat medication list if possible and a medication review appointment may be needed

 

 

  • Our surgery is an research active practice 
  • You may be invited to take part in research and 
  • Your patient records may be reviewed to check whether you are suitable to take part in a research study, before asking you whether you are interested or sending you a letter on behalf of the researcher. 
  • https:/www.hra.nhs.uk/information-about-patients/ which gives more information about how your information may be used in research.  

 
 

3. Your Lifestyle

 

Alcohol

Please answer the following questions which are validated as screening tools for alcohol use:

 

AUDIT–C QUESTIONS 

Scoring System

Your 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

7-9

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

 

 

A score of less than 5 indicates lower risk drinking

TOTAL:

 

                                    Scores of 5 or more requires the following 7 questions to be completed:             

AUDIT QUESTIONS

(after completing 3 AUDIT-C questions above)

Scoring System

Your Score

0

1

2

3

4

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 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 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

 

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

 

Have you or somebody else been injured as a result of your drinking?

No

 

Yes, but not in last year

 

Yes, during last year

 

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 last year

 

Yes, during last year

 

 

TOTAL:

 


 

3. Your Lifestyle - Continued

 

 

Smoking

Do you smoke?

 Never smoked   

 Ex-smoker       

 Yes    

Do you use an e-Cigarette?

 No                    

 Ex-User           

 Yes    

How many cigarettes did/do you smoke a day?

 Less than one     

 1-9        10-19  

 20-39     40

Would you like help to quit smoking?

 Yes                  

 No

 

 

For further information, please see: www.nhs.uk/smokefree

 

 

 

Height & Weight

Height

 

Weight

 

 

 

 

Women Only

Do you use any contraception?

 Yes      No   If needed, please book appointment.

Are you currently pregnant or think you may be?

 Yes      No   Expected due date:


 

 

4. Further Details

 

Named Accountable GP

The GP who has overall responsibility for your care is?

 

You are however entitled to make an appointment to see any GP of your choice, subject to availability.

 

Electronic Prescribing

If you would like your prescriptions to go electronically,
please provide details of the pharmacy you would like to use:

Pharmacy:

 

Patient Participation Group

Would you like to be involved in our Patient Participation Group?

 Yes      No

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services. 

 

 

Organ Donation

Blood Donation

 I am already a blood donor

 I wish to be a blood donor

 I do not wish to be a blood donor

Organ Donation

 I am already registered as a donor

 I wish to be a donor – all body part

 I wish to be a donor – for these body parts:

 I do not wish to be a donor

 

To register: Online: www.blood.co.uk/the-donation-process/recognising-donors 

                   Telephone: 0300 123 23 23 to speak to an advisor who will send out a donor card.

 

Signatures

Signature

 

 

I confirm that the information I have provided is true to the best of my knowledge.

 Signed on behalf of patient

Name

 

Date

 

 

 

Checklist

Please ensure the following are done and provided so that your registration can be completed successfully

 

Completed & Signed Above Form

 

Completed & Signed GMS1 Form

 

Photo Proof of ID   e.g. Passport, Photo Driving License or Photo ID card

 

Proof of Address    e.g. Bank statement, Utility Bill or Council Tax from within the last 3 months

 

 

Practice Use Only

Appointment

 Required

 Not Required          

 

 

Photo ID

 Passport

 Driving licence          

 Identity card        

 Other      

Proof of Address

 Utility Bill     

 Council Tax 

 Bank Statement  

 Other      

 

 


 

5. Sharing Your Health Record

 

Your Health Record

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

 

     Yes               (recommended option)

     No, except in an emergency

     No, never       (not recommended, please discuss this with your GP before ticking this option)

 

 

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

 

     Yes                  (recommended option)

     No

 

Your Summary Care Record (SCR)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

 

     Yes                  (recommended option)

     No

 

 

Signature

Signature

 

 

 Signed on behalf of patient

Name

 

Date

 


 

Sharing Your Health Record

 

What is your health record?

Your health record contains all the clinical information about the care you receive.  When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

 

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

 

  • ·        Sharing your contact details         This will ensure you receive any medical appointments without delay
  • ·        Sharing your medical history        This will ensure emergency services accurately assess you if needed
  • ·        Sharing your medication list         This will ensure that you receive the most appropriate medication
  • ·        Sharing your allergies                  This will prevent you being given something to which you are allergic
  • ·        Sharing your test results This will prevent further unnecessary tests being required

 

Is my health record secure?

Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

 

Can I decide who I share my health record with? 

Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

 

Can I change my mind?

Yes. You can change your mind at any time about sharing your health record, please just let us know.

 

Can someone else consent on my behalf?

If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

 

What about parental responsibility?

If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

 

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

 

How is my personal information protected?

will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

 

For further information, please see: www.nhs.uk/NHSEngland/thenhs/records


6. Online Access To Your Health Record

 

I wish to have online access to: Please tick all that apply

 View & book appointments

 View & request medication

 Access my coded medical record (contains any medical codes that have been recorded)

 Access my full medical record (contains medical codes and any free text that has been recorded)

 Access my Summary Care Record

 Complete online questionnaires

 

I wish to access my medical record & understand & agree with each statement: Please tick all that apply

 I have read and understood the ‘Important Information’ section below

 I will be responsible for the security of the information that I see or download

 If I choose to share my information with anyone else, this is at my own risk

 I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

 If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

 

Please bring photographic proof of your identification in order for the process to be completed

 

Signature

Signature

 

Name

 

Date

 

 

 

 

 

For Practice Use Only: 

Identity verified through

(tick all that apply)

 Self Vouching

 Vouching with information in record  

 Photo ID

 Proof of residence

 Professional Vouching

Name of Verifier

 

Date

 

Name of person who authorised and added to SystmOne

 

Date

 

Photocopied this page

 Yes – Name:

Passed for scanning

 Yes – Name:

 


Access to GP Online Services     

 

Important Information – Please read before completing form below

 

If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well.  It’s your choice.

 

It will be your responsibility to keep your login details and password safe and secure.  If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

 

If you print out any information from your record, it is also your responsibility to keep this secure.  If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

 

During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information.  Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal. 

 

The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.

 

Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

 

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news 

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. 

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care.  Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

 

For further information, please see:

www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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