Download New Patient Questionnaire

PATIENT QUESTIONNAIRE
Your New Patient Registration appointment is on ……………………………………… at ………………………………
Should you find you are unable to keep this appointment, even if you experience problems on
the same day, please telephone the surgery on 01246 244040 to cancel and rearrange this
appointment. We will not be able to proceed with your application to join the practice if you fail
to attend your new patient check appointment. If you have any queries contact the surgery for
advice on 01246 244040.
Please fill in as much as you can of this questionnaire. Please note any other medical history will
be transferred from your existing medical records once we receive them from your previous GP.
IF YOU HAVE NOT YET PROVIDED ONE IT IS ESSENTIAL THAT YOU BRING A LIST OF
YOUR CURRENT MEDICATION WITH YOU. PLEASE REQUEST THIS FROM YOUR
PREVIOUS GP
Patient information on Summary Care Record (SCR)
*PLEASE COMPLETE THE “DATA SHARING” SECTION.
THIS IS REQUIRED TO COMPLETE
THE REGISTRATION PROCESS. THANK YOU.
Your Summary Care Record (SCR) is a copy of key information held in your GP Record. It provides
authorised healthcare staff with faster, secure access to essential information about you – when you
need unplanned care or when your GP Practice is closed.
Summary Care Records will assist healthcare staff who may be treating you now and in the future.
This can improve your experience of care and also the safety and quality of that care.
Yours SCR already contains important information about any medicines you are taking, any allergies
you suffer from and any bad reactions to medicines that you have previously experienced. You may
want other details about your care to be added to your SCR – this is called additional information.
What is Additional Information ?
Additional Information is a summary of the information recorded by your GP Practice about you and
will include the following (when this is present in your GP Health Record):
Your long term health conditions - such as asthma, diabetes, heart problems or rare medical
conditions
Your relevant medical history – clinical procedures that you have had, why you need a particular
medicine, the care you are currently receiving and clinical advice to support your future care
Your health care preferences – you may have your own care preferences which will make caring for
you more in line with your needs, such as special dietary requirements
Your personal preferences – you may have personal preferences, such as religious beliefs or legal
decisions that you would like to be known
Immunisations – details of previous vaccinations, such as tetanus and routine childhood jabs
Specific sensitive information such as any fertility treatments, sexually transmitted infections,
pregnancy terminations or gender reassignment will not be included, unless you specifically ask for
any of these items to be included
How will Additional Information help me ?
Essential details about your healthcare can be very difficult to remember, particularly when you are
unwell. Having additional information in your SCR means that when you need healthcare, you will be
helped to recall this vital information.
There are already clear benefits for your care from having medication, allergy and adverse reaction
information available through your SCR. If you choose to add additional information, this can further
increase the quality of your care. Additional information can also empower you if you need some help
to communicate your complex care needs.
How do I include Additional Information in my Summary Care Record?
Your GP Practice may recognise that having additional information in your SCR will be of benefit to
you and may suggest this change. Alternatively, you can discuss your wishes with your GP Practice
and agree that information should be added to your SCR.
Additional information will only be included in your SCR after discussion between you and your GP
Practice, and only if you give your permission.
Once you have chosen to add additional information to your SCR, your GP Practice will continue to do
this and keep it up to date. Remember that you can change your mind at any time by simply informing
your GP Practice.
Children and the Summary Care Record
If you are the parent or guardian of a child under 16 and feel that they are old enough to understand,
then you should make the information in this leaflet available to them and support them to come to a
decision as to whether to supplement their SCR with additional information.
If you child cannot understand and you believe that they may benefit from additional information in
their SCR, then you can discuss this with your GP Practice.
Vulnerable Patients and Carers
Certain vulnerable patient groups such as frail elderly people or those with detailed complex health
problems can particularly benefit from additional information in their SCR. If you are a carer for
another person and believe that they may benefit from additional information in their SCR, then you
can discuss this with them and their GP Practice.
Data Sharing
The Summary Care Record (SCR)
You may recall receiving a letter on the subject of the National Summary Care Record (SCR). Your
SCR contains up to date information relating to your medications, any allergies and adverse reactions
you have only. You will always be asked by the clinical staff for your permission to view your SCR.
I wish to Opt in to SCR for medications, allergies and adverse reactions only
I wish to Opt in to SCR for medications, allergies, adverse reactions and additional information
I wish to Opt out to SCR
Enhanced Data Sharing Model (eDSM)
This is a new local information sharing initiative which allows services such as Physiotherapy, District
Nurses and various hospital departments to share your detailed GP Record. Your GP will have access
to view entries made on your record by other services, with your consent.
Please answer the following:
I am happy for information on our computer systems to be seen by Clinicians treating you whilst in
other health care settings (and who use the same system)
The Practice to view the information recorded about you at other healthcare settings who use the
same system as your Surgery
NHS Number __________________________
Title:
Mr
Mrs
Miss
Marital Status: Single
Ms
Date of Birth ____________________
Other ___________ Sex: Male/Female
Married
Age _____
Divorced
First Name ____________________
Surname _________________________
Previous Surname/s ____________________
Town & Country of Birth _______________
Address __________________________________________________________________
________________________________________
Post Code ______________________
Occupation _______________________ Next of Kin ____________________________
Next of Kin Contact ________________________________________________________
Ethnic Origin – Please circle below which best describes your ethnic group:
WHITE/MIXED/ASIAN/BLACK/OTHER ETHNIC GROUP
Main Language spoken ___________________
Home telephone number _______________ Mobile telephone number _________________
Can we contact you via SMS:
YES/NO
Work telephone number ___________________
PERSONAL MEDICAL HISTORY
Height _______________________
Weight _______________________
Allergies _____________________
BP ____________________________
Do you have a history of e.g. Blood pressure, Angina, Asthma, Anticoagulation (INR)
Cardiovascular disease, COPD, Diabetes, Epilepsy, Mental Health Problems, Stoke/TIA
any major operations or any other illnesses you think we might need to know about
_______________________________________________________________
_______________________________________________________________
Please list any operations you have had __________________________________
_______________________________________________________________
Do you have any disabilities __________________________________________
_______________________________________________________________
COMMUNICATION
Do you have a disability, impairment or sensory loss which affects your ability to communicate?
If yes – please specify: ___________________________________________________
_____________________________________________________________________
IT IS ESSENTIAL YOU PROVIDE A
SMOKING STATUS
CURRENT MEDICATION SUMMARY FROM
YOUR PREVIOUS SURGERY
YOUR HEALTH tick which applies to you:
Please list below tablets and dosages & how
medicine is taken
Smoker
How many per day? …..
………………………………………………………………………..
………………………………………………………………………..
………………………………………………………………………..
………………………………………………………………………….
Ex-smoker
If yes – when ……….
…………………………………………
…………………………………………………………………………
…………………………………………………………………………
………………………………………………………………………..
Never Smoked
Are you receiving any medication prescribed by a specialist, for example injections at an
outpatient clinic?
If yes – please specify: ___________________________________________________
_____________________________________________________________________
For the following questions please circle the answer which best applies.
1 drink = ½ pint of beer or 1 glass of wine or 1 single spirit.
How many units do you drink per week
1.
How often do you have eight or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or
almost daily
2. 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
Never
Less than monthly
Monthly
Weekly
Never
Less than monthly
Monthly
Weekly
Daily or
almost daily
3. How often during the last year have you failed to do what was normally expected of you because of your
drinking?
Daily or
almost daily
4. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or
suggested you cut down?
Daily or
almost daily
FAMILY HEALTH
Have any of your family/close relatives had any of the following:
YES
NO
YES
Stroke
Asthma
Heart Attack
Cancer
High Blood Pressure
Diabetes (sugar)
NO
Fits
IF you answered YES please give brief details ………………………………………………………………………………………
Please list any other illnesses you think we might need to know about :
_____________________________________________________________________________
_____________________________________________________________________________
VACCINATIONS:
Last Tetanus _____________________
Last Polio _____________________________
Other immunisations ___________________________________________
FEMALES ONLY
Are you currently pregnant:
YES/NO
Which method of contraception do you use ____________________________________________
Approximate date of your last smear ________________________________________________
Approximate date of you last breast screening _________________________________________
PHYSICAL ACTIVITY
Do you exercise:
YES/NO
How many times per week _______________________
How long for _____________________________________________________________________
What types of activity ______________________________________________________________
ONLINE ACCESS
If you would like to register for online appointment booking, repeat prescription ordering and access to a
Summary of your Medical Record, please ask at Reception to receive your confidential log in details
CARERS
Do you look after a relative, child or friend who needs support to a physical or learning disability/illness?
YES/NO
If yes and you would like more information please ask for our Carer’s leaflet – you may be entitled to free
annual influenza vaccinations.
Do you have a carer helping you at home? If yes please give details
……………………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………………
FAMILY HISTORY
Have your parents or siblings had any of the following when they were UNDER 65 YEARS OF AGE (if yes please
give brief details)
Stroke
YES/NO
________________________________________
Heart Attack
YES/NO
________________________________________
High Blood Pressure YES/NO
________________________________________