Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
RIVERSIDE SURGERY Barnard Avenue, Brigg, DN20 8AS NEW PATIENT HEALTH QUESTIONNAIRE Title: Mr, Mrs, Miss, Ms: ………………….. Date of birth: ………………………………………..... First names: ………………………………….…. Surname: ……………………………………..…………. Home Address: Home Tel: ………………………………………………. ……………………………………………………….. Work Tel: ……………………………………………… ……………………………………………………….. Mobile: …………………………………………………… Postcode: ………………………………………… Email Address: ………………………………………… Are you happy to receive text messages from the surgery? Please state Yes or No: ……………………………… Occupation: …………………………….……... Previous surnames: ………………………………….. (If applicable) School/College: (If school please state which school) Are you registering with a GP for the first time? ……………………………………………………….. Yes or No (please state): ……………………………….…….. If you are registering for the first time you will need to provide a valid passport or driving licence and a utility bill from your place of residence. Please give details of your previous GP (STAFF USE ONLY) Passport provided: Yes or No: ……….. Practice Name: ……………………………….. And Utility Bill provided: Yes or No: ……….. (If applicable) Dr Name: ………………………………………. Address: …………………………………………. ………………………………………………………. Postcode: ………………………………………… Telephone: ………………………………………. 1 November 2016 ETHNIC GROUP – please circle which one applies to you White European Black Caribbean Asian Indian Irish African Pakistani Chinese Other:(please state): ………………………………………………………………………………………………………………….… Main spoken language: (please state): Interpreter Required? ………………………………………………………. Yes or No: …………………………………….. PERSONAL MEDICAL HISTORY Height: ………………………………………….. Weight (approx): ………………………………. Do you suffer from the following: Please state Yes or No Heart disease: ……………………………….. Hypertension: ………………………………………… Diabetes: ……………………………………… Asthma: ………………………………………………. COPD: …………………………………………… Are you allergic to anything? (example medication or other) Please state: ………………………………….. If yes please list your allergies: ……………………………………………………….…… ……………………………………………………………. Please list any serious illnesses/operations/accidents/disabilities (and for any pregnancy related problems) and the year they took place: …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… 2 November 2016 PERSONAL MEDICAL HISTORY CONTINUED Are you currently receiving any hospital care? Any previous surgical procedures? Please state: ………………………………….. Please state: ………………………………….. …………………………………………………... ………………………………………………….... …………………………………………………... ………………………………………………….... FAMILY HISTORY Please state any serious illness, in particular heart disease, strokes, high …………………………………………………………… blood pressure, diabetes or any inherited disease. …………………………………………………………… Is there a family history of bowel/breast, …………………………………………………………… prostate or any other recurring cancer. …………………………………………………………… Please state relationship and age: …………………………………………………………… MEDICATION Please supply a copy of your current repeat prescription – no medication will be given without evidence and authorisation from the GP. (Medication takes 1 week to process) Please list any medication and the dose that you are currently taking: ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ALCOHOL Please take a few moments to complete our alcohol form attached to this registration form. 3 November 2016 SMOKING Do you smoke? Please state: …………………… Have you ever smoked? Please state: …………………… When did you give up? Please state: …………………… If yes, please state how many a day: Cigarettes ………………………………………………………………….. Rolled tobacco ………………………………………………………………….. Cigar ……………………………………………………………….…. Pipe ……………………………………………………………….….. Electronic Cigarette …………………………………………………………………... WOMEN Have you ever had a cervical smear? Please state: If YES please detail when and where: ………………………………………………………. …………………………………………………………… ………………………………………………………. ………………………………………………………. CONTRACEPTION Are you prescribed any method of Please state what type: contraception? …………………………………………………………… Please state: ………………………………………… Would you like information about FOR STAFF USE ONLY: contraception to be sent to you? Information sent to patient: …………………. Please state: …………………………………………. SUMMARY CARE RECORDS (SCR) – sharing of medications, allergies and adverse reactions The information your doctor holds may be used by secondary care if you do not wish this to happen you will need to complete an opt out form which is available at reception or on our website: www.riversidesurgerygps.co.uk Your data will not be shared with any other third party. Please sign to accept. Signed: …………………………………………… 4 November 2016 Date patient completed this form: Patient signed: ………………………………………………………….. ……………………………………………………… YOUR ACCESSIBLILITY NEEDS We want to get better at communicating with our patients. We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. Please tell us what your communication requirements are (eg, braille, large print ect) Please state: ……………………………………………………………………………………………………….. Please tell us what communication requirements you have () RESEARCH We are a Research Practice; if you are interested in participating in any of our clinical trials please state Yes or No: ………………………………………………………………………………………………………………………….. Please note it may take up to 7 working days to process your application form FOR STAFF USE ONLY New Patient questionnaire information entered on to Emis Web Date Entered on: ………………………….. Patient No: …………………….. By Who: ……………………………………… Thank you for completing this questionnaire Welcome to Riverside Surgery 5 November 2016