Identifying Patient Needs Protocol & New Patient ...



Barbourne Health Centre

New Patient Registration Form

Please complete this confidential questionnaire

Please be advised that we need proof of ID (i.e.: passport or driving license) and proof of address before we can accept your registration. If you haven’t got all this with you, then please take the forms away and bring back together with all the relevant paperwork.

Please complete in BLOCK CAPITALS and tick the boxes as appropriate.

If you are newly arrived in this country, please bring your passport to confirm your date of birth and entitlement to NHS treatment.

Please complete a separate form for each family member to be registered.

|Full Name: |Landline Number: |

|Mr / Mrs / Miss / Ms / Other…….. |Work Number: |

|Address and Postcode |Mobile Number: |

| | |

| | |

| |TEXT REMINDERS ARE SENT FOR APPOINTMENTS.IF YOU |

| |DONOT WISH TO RECEIVE A REMINDER PLEASE STATE : |

| |Y/N |

| |E-mail Address: |

| | |

| |Next of Kin and relationship to patient: |

| | |

| |Next of Kin Contact Number: |

|Date of Birth: |Any previous surnames? |Town & Country of Birth |

|Marital Status: | |

|Names & Ages of Children | |

|Housing |House |Maisonette |Flat |Mobile Home |NHS Number (If Known) |

|(Select one) | | | | | |

|Previous Home Address and Postcode: |If applicable, date you |

| |first came to live in Britain: |

| | |

|Previous Doctor Name, Address and Telephone No.: | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | |

|If returning from |Your Service or Personnel Number |Your Enlistment Date |

|Armed Forces: | | |

|Your |

|height: |

|Your |

|Religion: |

|Your Ethnic Origin: |White (UK) |White (Irish) |White (Other) |

|(select one) | | | |

|Caribbean |African |Asian |Other Mixed |

| | | |Background |

|Indian / |Pakistani / |Bangladeshi / Brit Bangladeshi |Other Asian |

|Brit Indian |Brit Pakistani | |Background |

|Other Black |Chinese |Other |Ethnic Category |

|Background | | |not stated |

| |

|Your main or 1st |English |Hindi |Gujurati |Urdu |Bengali /Sytheti |

|language Spoken / | | | | | |

|Understood: | | | | | |

|(select one) | | | | | |

| |

|Smoking, Alcohol Consumption and Exercise: |

|Are you currently a smoker? |Yes |No |Have you ever |

| | | |been a smoker? |

|If you are a smoker and want to stop, please speak to your local | | |

|pharmacy about smoking cessation services. | | |

|How often do you exercise? |No. times per week |Type(s) of | |

| | |exercise: | |

| |

|Your Medical Background: |

|What illnesses have you had & | |

|When? | |

|What operations have you had and | |

|When? | |

|Do you have any medical problems | |

|at present? | |

|Please list any tablets, medicines| |

|or other treatments you are | |

|currently taking: | |

|(incl. dose + frequency) | |

|Previously set up with a pharmacy |Please let us know if you were. We will need to take your old Pharmacy off your records if you are now out|

|for Electronic Prescriptions?? |of their area. If you want to set up again with a new pharmacy, please drop in to the one of your choice |

| |and get set back up. Thanks |

| | |

| |Electronic prescriptions are more quickly processed as they go directly into our computer system. |

| |Please ask at reception if you wish to know more |

|Are you able to administer your |Yes |No – please detail specific issues (e.g. swallowing, opening containers) |

|own medicines? | | |

|Are there any |Diabetes |Heart Attack |Heart attack under age of 60 |Bowel Cancer |

|serious diseases that affect your | | | | |

|Parents, Brothers or Sisters | | | | |

|(tick all that apply) | | | | |

| |Breast Cancer |High Blood Pressure |Asthma |Stroke |

| |Thyroid Disorder |Any other important Family Illness? |

| |

|What immunisations |Diphtheria |Measles |German Measles |

|have you had? | | | |

|(please tick all | | | |

|that apply) | | | |

| |

|Specific Needs: |

|Please detail below any specific needs you have so the Health Centre can ensure they are identified and accommodated by taking the |

|appropriate action: |

|Please state any Sensory Impairment you have | |

|(i.e. Speech, Hearing, Sight): | |

|Are you an ‘Assistance Dog’ User? | |

| | |

|Please state any Physical disabilities you | |

|have: | |

|Please state any Mental disabilities you have:| |

| | |

|Please state any requirements you have to be | |

|able to access the Health Centre premises | |

|Please state any Religious or Cultural needs: | |

|Do you require the help of a Translator / | |

|Interpreter? | |

|Please state any specific nutritional | |

|requirements you have: | |

|Please state any allergies and sensitivities | |

|you have: | |

|Please state any phobias you have: | |

| | |

|If you are a Carer, please state the name / |Person Cared For Contact Details: |

|address / phone number of the person you care | |

|for: | |

|If you have a Carer, please state their name /|Carer Contact Details: |

|address / phone number and sign here if you | |

|wish us to disclose information about your | |

|health to your Carer. | |

| | Signed: |

| |Date: |

|Have you ever had a social worker or received |Yes/No | |

|additional help from the early help hub | | |

| | | |

| | | |

| | | |

|Do you have a “Living Will” |Yes / No |If “Yes”, |

|(a statement explaining what medical treatment| |can you please bring a written copy of it |

|you would not want in the future)? | |to your New Patient Consultation |

|Have you nominated someone to speak on your |Yes / No |If “Yes”, please state their name / address / phone number: |

|behalf (e.g. a person who has Power of | | |

|Attorney)? | | |

| |

|Women only: |

|When was your last smear |Date |Was this at your |Yes |NO |

|done? | |GP’s Surgery? | | |

|What was the result | |

|of the smear? | |

|Date of last mammogram |Date |Method of contraception (if | |

|(if applicable): | |used): | |

|Do you wish to see a doctor in this Health Centre for contraceptive services (including |Yes |NO |

|the pill, coil or cap)? | | |

| |

|Summary Care Records. |

|The NHS are changing the way your health information is stored and managed. |

|The NHS Summary Care record is an electronic record of important information about your health. |

|It will be available to health care staff providing your NHS Care. |

|It shows Allergies and medication, this is so other health care professionals are able to treat you quicker if ever needed. |

| |

|You can find more information regarding summary care records by searching the below link on the internet. |

| |

| |

| |

|There is an OPT-OUT form attached if you do not wish other health professionals to see your records |

|Please make sure you understand the implications to opting out if you wish to do so |

| |

|Are you happy to have a Summary Care |Yes |No | |

|Record? | | | |

| |

|Patient Participation Group |

|The Health Centre is committed to improving the services we provide to our patients. |

|To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better. |

|By expressing your interest, you will be helping us to plan ways of involving patients that suit you. |

|It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Health Centre. |

|If you are interested in getting involved, please tick the box below and we will arrange for the Health Centre Patient Participation Group |

|Application Form to be given to you at your initial consultation. |

|Yes, I am interested in becoming involved in the Health Centre Patient Participation Group (Please tick the “Yes”|Yes |

|Box) | |

| | |

|Patient Access through Emis Web | |

| | |

|Patient Access lets you use the online service of our practice. This includes arranging appointments, repeat | |

|medication, secure messages, viewing parts of your medical records and updating your details. | |

| | |

|If you wish to sign up please come to reception with proof of ID and we shall print you off all the relevant | |

|passwords and paperwork for you to set it up at home. | |

|There is also an app available to download on android and iOS mobile phones. | |

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|Patient | |Signature on | |

|Signature: | |behalf of Patient: | |

|Date | | | |

You are entitled to have a new patient health check with one of our Health Care Assistants when you register with us.

Please book in, it is a 10 minute appointment which will include having your height, weight and blood pressure taken, and a specimen of urine for testing (it would be helpful if you would bring a specimen with you when coming to the Health Centre).

The Consultation will also establish relevant past medical and family history, including:

• Medical factors - illnesses, immunisations, allergies, hereditary factors, screening tests, current health

• Social factors - employment, housing, family circumstances

• Lifestyle factors - diet and exercise, smoking, alcohol and drug abuse.

Thank you for completing this form

For more information about the services we offer, see our website:

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