Download new patient summary sheet

New patients form –incl children
Hillview Medical Centre
Please complete all sections of the form
1.
Your details – please complete the boxes below
1.1 Name
(write in
capital letters)
1.2 Date of birth
1.3 Mobile
phone number
1.5 Email
address
1.4 Home phone
number
1.6
Contacting you
In the next few months, we are hoping to be able to start offering our patients the facility to be
contacted by email and / or text. We also need to know if you are happy for us to leave messages for
you on your answer phone if we need to get in touch with you.
1.6 (a) Are you happy for us to contact you by email?
Yes
/
No
(please circle)
(internal use: add code 9NdS to patient record if ‘yes’)
1.6 (b) Are you happy for us to contact you by text?
(please circle)
Yes
/
No
Yes
/
No
(internal use: add code 9NdP to patient record if ‘yes’)
1.6 (c) Are you happy for us to leave messages for you on your answer
phone? (please circle)
(internal use: add code 9Ndi to patient record if ‘yes’)
1.7 First
language
1.8 Allergies
1.10 Are you
a Carer?
1.8 Do you need
an interpreter?
1.9 Marital
status
Yes
/
No
1.11 How often
do you usually
visit your GP
surgery?
If yes – please
write in who
for
(please tick)
1.12 Would you like to help us to improve our services by
joining our virtual patient participation group?
Yes
/
No
/
No
Regularly
Occasionally
Very rarely
Yes
If you are happy for us to occasionally contact you by email about
what you think of our services – please circle ‘yes’ in the box to
the right.
2.
Sharing your medical records with others
The NHS would like to share your data with others in a number of ways. Please answer the questions
below so that we know how you wish us to share your data.
2.1
Summary care records (www.nhscarerecords.nhs.uk)
Hillview Medical Practice is a part of the national Summary Care Record program. This enables each
patient to have a summary of their key medical information held securely on the NHS central
database, known as the NHS spine. The summary record can be used in an emergency if you needed
treatment when access to the medical record held by your GP was not available; for example if you
______________________________________________________________________________________
Saved in CQC under registration \ new patient registration pack – Sept 2014
Page 1 of 4
New patients form –incl children
Hillview Medical Centre
call the doctor out of hours. You will always be asked to give permission for this record to be viewed
and you have the right to decline.
Please indicate below whether you would like to have your own Summary Care Record by indicating
your decision below. A full explanation of each choice follows:
Options – please select one of these by ticking the box to the right of the
option
1
2
3
Tick
one
I wish to have a Summary Care Record containing my medications allergies
and adverse reactions or sensitivities to medications
I wish to have a Summary Care record with the above plus additional important
medical information held on my record
I do not wish to have a Summary Care Record
(internal use only – add relevant option during patient registration process)
2.2
Care Data (www.nhs.uk/caredata)
Information about you and the care you receive is shared, in a secure system, by healthcare staff to
support your treatment and care.
It is important that the NHS can use this information to plan and improve services for all patients.
The NHS would like to link information from all the different places where you receive care, such as
your GP, hospital and community service, to help them understand the full picture. This will allow
them to compare the care you received in one area against the care you received in another, so they
can see what has worked best.
Information such as your postcode and NHS number, but not your name, will be used to link your
records in a secure system, so your identity is protected. Information which does not reveal your
identity can then be used by others, such as researchers and those planning health services, to make
sure we provide the best care possible for everyone.
How your information is used and shared is controlled by law and strict rules are in place to protect
your privacy.
NB. Please be aware that there are times when, by law, we may have to release information about
you (for example, if there is a public health emergency).
Options – please select one of these by ticking the box to the right of the
option
1
2
Tick
one
I do not want any of my personal confidential information held at my GP practice
to be shared with anybody outside my GP practice
I do not want any personal confidential information about me that the NHS has
gathered from any health and social care setting, to be shared with other
organisations
(internal use only – add relevant code to patient records: option 1: 9Nu0 / option 2: 9Nu4)
2.3
Sharing your records with other community health and social care teams
We often work with other clinicians such as district nurses, community midwives, community
matrons, health visitors, social services, palliative care. These teams are not employed by our
practice but they may need access to your records to support you appropriately. They abide by all of
our rules around patient confidentiality.
Are you happy for us to share your records
with the community teams that we work with
to provide your health support?
(please circle)
Yes
/
No
______________________________________________________________________________________
Saved in CQC under registration \ new patient registration pack – Sept 2014
Page 2 of 4
New patients form –incl children
3.
Your next of kin details – please complete the boxes below
3.1 Next of kin
name
(please write in
capital letters)
3.3 Is your next
of kin male or
female?
(please circle)
4.
Hillview Medical Centre
3.2 Next of
kin telephone
number
Male
/
Your ethnic background
3.4 How is
your next of
kin related to
you?
– please tick the appropriate box
Female
White British
Black African
Bangladeshi
White Irish
Black Caribbean
Indian
White - any other
white background
Black - any other black
background
Pakistani
Chinese
Any other ethnic background –
please state:
Any other
Asian
background
5.
Do you smoke? - please tick the appropriate box underneath the options
Option 1
Option 2
Option 3
Option 4
I have never
smoked
I used to smoke
I am a current smoker
(please also write in
the date when you
stopped)
(please also write in
how many cigarettes
you smoke in a day)
I am a current smoker and
would like the number for the
Stop Smoking Service 0845 602 3608
(internal use – code
137S)
(internal use – code
137R)
(internal use –
code 1371)
6.
(internal use – code 8CAL)
How much alcohol do you drink? - please circle the appropriate boxes
( Please note - the scores are
for internal use only)
6.1 How often do you have
a drink that contains
alcohol?
Score 0
Never
Score 1
Monthly or
less
Score 2
2 – 4 times
per month
Score 3
2 – 3 times
per week
Score 4
4 + times
per week
______________________________________________________________________________________
Saved in CQC under registration \ new patient registration pack – Sept 2014
Page 3 of 4
New patients form –incl children
6.2 How many standard
alcoholic drinks do you have
on a typical day when you
are drinking?
6.3 How often do you have
6 or more standard drinks
on one occasion
7.
Hillview Medical Centre
1–2
3–4
5–6
7–9
10 +
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Children’s details (if also being registered with the practice)
Name of child
Date of birth
Address and
telephone
number (if
different to
yours)
Signature
Allergies
Ethnic
background (if
different to
yours)
Date
Internal use only
Name of person checking the form
Form details checked
ID / proof of address etc checked
Named GP for patients (write in name of GP to
confirm you have told the patient/s)
Named GP for patients (confirm you have added
codes 67DJ and 9NN60 to all the new patient records)
______________________________________________________________________________________
Saved in CQC under registration \ new patient registration pack – Sept 2014
Page 4 of 4