Download Dr Paul Manchett - Stockbridge Surgery

Dr Paul Manchett
Dr Adrian Townsend
Dr David Simpson
Dr Natalie Avery
Dr Edward Gibbons
Dr Claire Walsh
Dr Julia Snyder
Stockbridge Surgery, New Street, Stockbridge, Hampshire. SO20 6HG
Welcome to Stockbridge and Broughton Surgeries.
It often takes many weeks before the records arrive from the previous Doctor.
To help us until then, please fill in the form below as completely as you can.
Please complete or tick box next to the most appropriate statement.
1
Personal Details
Surname:
_________________
Forenames: _______________________
Title
_________________
Date of Birth:
_________________
Address:
____________________________________________________________________
Sex:
Male / Female
Marital status _______________________
____________________________________________________________________
Post code:
_________________
Home Tel:
_________________
Work Tel: _______________________
Mobile:
_________________
Occupation: _______________________
2
Health
2.1 Smoking
2.2 Alcohol
I have never smoked
Gave up ? years ago/smoked ? per day
I smoke less than 1 cigarette per day
I smoke 1-9 cigarettes per day(light)
I smoke 10-19 cigarettes per day(mod)
I smoke 20-39 cigarettes per day(hvy)
I smoke more than 40 cigarettes per
day (vhvy)
I smoke ? cigars per day
I smoke a pipe. ? oz’s per week
I smoke ‘roll your own’ cigarettes
A unit is one pub measure of spirits, one glass of
wine or half a pint of beer or cider
/
How many units per week do you drink?
(please state approximate number)
2.3 Height/Weight
Height: ………ft………ins, or……………m
Weight: ………st………lbs , or …………kg
Please note this is a Personal History Form; please complete a Registration Form GMS1 at the
surgery
Please turn over
3
Family History
Does / Did she / he have?
Relation
Living
or
Deceased
Age
Heart
Disease
High
Blood
Pressure
Diabetes
( Please tick box if YES)
Glaucoma
Asthma
Stroke
Cancer
(Please
state type
e.g
breast,
bowel)
Father
Mother
Other Blood Relatives ( grandmother/grandfather/sister / brother)
4
Allergy to Medication
Are you allergic or sensitive to any medication?
*If YES please name / give further details:
5.
First Spoken Language
6.
Ethnic Category
White
Mixed
Asian
British
Irish
Other White
White/Black Caribbean
White/Black African
White/Asian
Other Mixed
Indian
Pakistani
Bangladeshi
Other Asian
YES* / NO
…………………………………………
…………………………………………
………………………………………
Please specify………………………………………………….
Black or Black British
Other Ethnic
Black Caribbean
Black African
Other Black
Chinese
Japanese
Other Ethnic Category
Declined
THANK YOU for completing this form for our records.
 If on medication, please arrange a New Patient Health Check with a doctor. Please bring a record of all
your medications and a urine sample when you attend.
Please note this is a Personal History Form; please complete a Registration Form GMS1 at the
surgery
F.A.S.T
ALCOHOL QUESTIONNAIRE
1.
MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
1 drink = ½ pint of beer or 1 glass of wine or 1 single spirits
(√) Please tick one box below
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?
(√) Please tick one box below
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 drinking?
(√) Please tick one box below
Never
Less than
monthly
Monthly
Weekly
Daily or almost
daily
()
4.
In the last year has a relative or friend, or a doctor or other health worker been
concerned about your drinking or suggested you cut down?
(√) Please tick one box below
No
()
Yes, on one occasion
Yes, on more then one occasion
Dr Paul Manchett
Dr Adrian Townsend
Dr David Simpson
Dr Natalie Avery
Dr Edward Gibbons
Dr Claire Walsh
Dr Julia Snyder
Practice Manager: David Wharton
STOCKBRIDGE SURGERY NEW STREET STOCKBRIDGE HAMPSHIRE SO20 6HG
Tel: 01264 810524 Fax: 01264 810591
e-mail: [email protected]
website: www.stockbridgesurgery.co.uk
Repeat prescription reorder form
When you receive your repeat prescriptions which have been with dispensed by the surgery
or by the chemist you should find attached a reorder slip.
You may use this slip to reorder your medication or you may order your medication online
using EMIS Access.
At the bottom of the reorder slip it will state a review date. You need not worry about this
date; it is used by the surgery.
However, if when processing the item the Doctor would like you to make an appointment with
the surgery to see the Doctor, Practice Nurse or Phlebotomist this will be either printed or
written at the bottom of the reorder slip underneath the review date. If this request is on your
reorder slip then you need to call the surgery to make an appointment.
In order to use EMIS Access you need to ask at Reception for a Practice ID, Personal
Access ID and on-line access instructions.
Stockbridge Surgery
Partners: Dr P Manchett, Dr A Townsend. Dr D Simpson, Dr N Avery, Dr E Gibbons, Dr C Walsh
Our Dispensing Service
The Stockbridge Surgery dispensary is available for use by our patients living more than a
mile (1.6 km) as the crow flies, from the nearest pharmacy. The law does not extend the
right to patients within the 1 mile zone.
The opening hours are Monday – Friday 8.15am to 6.30pm (closed for lunch between 12.451.45pm). Saturday 9am to 12pm (for collection of medication and prescriptions
The dispensary is managed by Sophie Grant. She has a dedicated team of dispensers who
run an efficient, well organised service. They are happy to discuss your queries and will refer
to a doctor if required.
We also run a smaller dispensary at Broughton which is useful for acute illnesses and for
picking up your repeat medication.
We pride ourselves in holding a large stock of medicines and we can usually provide you
with medication to treat acute illnesses before you leave the surgery. On rare occasions we
may have to obtain them from our suppliers; this is usually achieved within 24 hours.
Re-ordering medication
There are 4 ways to re-order your medication:
1
Internet.
The system (EMIS) is easy to use and can be accessed via our website:
www.stockbridgesurgery.co.uk
You will need to contact the surgery to obtain a unique log-in number to set up your access
process. Please ask at reception for details.
2
In person.
Use the repeat medication form enclosed with medicines. Simply tick the required items and
leave the form at your usual drop off point i.e. one of our surgeries or at the appropriate
village post office.
3
Post.
Mail the repeat form or a clearly written request to Stockbridge Surgery [address overleaf]
4
Fax
Fax to Stockbridge Surgery [number overleaf]
Order in good time
In general, you should allow 48 hours from handing in your prescription to collecting the
medication. If you need the drugs sooner, please check with our Dispenser first that they are
in stock,
In order to prevent waste, only re-order medication that you currently need.
Collection & Delivery Service
We provide a collection and delivery service three times a week in the following areas:
Chilbolton, King’s Somborne, Leckford and Over Wallop.
We also have a weekly service which covers Grateley. Nether Wallop, Lockerley and the
West Tytherley areas.
We pick up all repeat medication requests as they all need to be processed by us. For our
dispensing patients we will deliver your medication back to the appropriate village post office,
usually within two working days.
Non-dispensing patients can collect their forms from the designated surgery (Stockbridge or
Broughton). We will post your new prescription form back to you if supplied with a stamped,
addressed envelope. Prescriptions to be dispensed by the local town pharmacy are collected
from us each day after processing.
Emergency Pharmacies
When the Surgery is closed, you can take your prescription to any Pharmacy of your choice
to be dispensed.
Cover is also provided on the following days in Andover:
Saturdays
Boots the High Street, Andover, to 5.30pm
Boots the Chemist, Chantry
Centre, to 6.00pm
Superdrug, High St, Andover to 5.30pm
Sundays
Boots the Chemist, Chantry
Centre, Andover. 10.00—4.00
Further details of Pharmacy late opening and weekends are displayed at the Surgery.
Comments
We welcome your comments
regarding the dispensary. If you have any suggestions to improve the service or issues you
would like to raise, please speak to either Veronica Ayers, Senior Dispenser, or the Practice
Manager, Mr David Wharton.
Stockbridge Surgery
New Street
Stockbridge
Hampshire
SO20 6HG
Stockbridge : 01264 810524
Broughton : 01794 301210
Dispensary : 01264 811021
Fax: 01264 810591
Email: [email protected]
Do something amazing today !
When you give blood, you will be doing one of the most amazing things anybody could
dream of – saving a life. You can enable someone to receive a gift of a desperately needed
transfusion.
Every day of the year, hospitals in England need 10,000 donations of blood – and the
demand is rising all the time as medical techniques become ever more sophisticated.
But only 5% of the UK population currently give blood
It is all types of blood that are needed – not just rare ones. In fact, the commoner the blood,
the more is needed. So even if your blood id O, for example – you can be sure that by
donating regularly, two or three times a year, you really are doing something amazing
By enrolling as a blood donor, or if you have given blood but not recently, why not enrol
today?
It could not be simpler, just take two minutes to complete the form below and hand it in at the
surgery reception.
You will then be entered on to the NHS Blood Donor Register. At some point, you will be
contacted by the National Blood Service for details of the next session near you
It’s amazing the difference you’ll make !
……………………………………………………………………………………………………………
NHS Blood Donor registration�
I would like to join the NHS Blood Donor Register as someone who may be
contacted and who would be prepared to give blood.
Tick here if you have given blood in the last 3 years
Name and Signature confirming consent to inclusion on the NHS Blood Donor
Register
…………………………………………………………………………Date…………………………..
Home address
………………………………………………………………………Postcode………………………
For more information, please ask for the leaflet on joining the NHS Blood Donor
Register. My preferred address for donation is: (only if different from above e.g. Your
place of work)
....................................................................................................................................................
..................................................................................................Postcode:……......................
Hampshire LINk (Local Involvement Network)
We are seeking our patients’ support in asking you to consider signing up to Hampshire LINk
The Stockbridge Practice is part of the WINCAR (Winchester City and Rural Practices)
Practice Based Commissioning Group. One of the initiatives of this group is to encourage
patients from the 13 practices to join up to the Hampshire LINk
The purpose of the Hampshire LINk is to give you the opportunity to influence your local
health and care services. Anyone can get involved and it has been set up to make sure that
people in Hampshire get the health and social care services they need
LINks are made up of individuals and community groups who work together to improve local
services. The job of a LINk is to find out what people like and dislike about local services,
and work with the people who plan and run them, to make them better
Hampshire LINk wants to hear about your experiences of health and social care services and
your ideas for improvement or change. It has the power to implement small changes and
influence big changes
For more information please ask for a LINk leaflet
Thank you for taking the time to read this note.
Drs Manchett, Townsend, Simpson, Avery, Gibbons, Walsh and Snyder