Download Adult registration pack

Dr H G J Mistry, Dr F Z M Kotwal, Dr N Sehgal, Dr S Brackenbury
Thomas Walker Surgery, Princes Street, Peterborough, PE1 2QP
All applications ideally need to be supported by proof of photographic identity, bring in a photocopy of either a
driving license, passport, national identity card or residency if you are unable to provide photo identification you
may bring in a. bank statement, utility bills, tenancy agreement and mortgage statement to confirm residency.
For office use only:
Please tick to confirm Identification seen and confirmed by
Please tick if invited for NPC and date
……………………………………..
……………………………………..
ADULT REGISTRATION FORM
CONFIDENTIAL QUESTIONNAIRE
Please answer the questions below as fully as you are able and bring this questionnaire with you when
you come to surgery, it will form part of your medical records.
TODAY’S DATE :
Surname:
Previous Surname
Forenames
Gender
(please circle)
Date of birth
Male
Female
NHS number
The town/Country of birth
Date entered UK
Marital Status:
Occupation
Address:
Tel No: ............................................................................ Work No: ……………………………………………….
Mobile No:......................................................................... Email Address:………………………………………..
Can we use this mobile number to send text messages to you, to remind you of appointments
It will be your responsibility to ensure we hold your correct telephone number.
YES
□
NO □
Your signature :
Please give the name and address of your previous Doctor
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Please give details of the address you lived at when you were registered with this Doctor
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
To help you make the most of every consultation with a Doctor or a Nurse can you give us the
following information:
YES
NO
Do you use an auditory aid (e.g. a hearing aid)?
□
□
Do you use British Sign Language?
□
□
Do you lip-read?
□
□
YES
NO
Are you a carer?
□
□
YES
NO
Do you have a carer?
□
□
YES
NO
If you are a carer, or have a carer –
do you already have support and help from
the Social Service?
□
□
Would you like support and
advice from Social Services?
□
□
If yes, we can send you out a service and support carers - information leaflet
Height………………………………………m
Do you smoke?
Weight……………………………………kgs
YES
□
Have you ever smoked?
□
If you have smoked, when did you stop?...........................................
NO
□
□
If you would like to give up smoking you can contact the stop smoking service for advice and
support on
Freephone: 0800 376 56 55
Additionally some patients may prefer to use the internet for further information,
www.peterborough.nhs.uk/stop
Do you do any form of regular exercise?
YES
□
NO
□
PLEASE CIRCLE THE MOST APPROPRIATE ANSWER TO EACH QUESTION:
This is one unit of alcohol…
…and each of these is more than one unit
AUDIT – C
Scoring system
Questions
How often do you have a
drink containing alcohol?
How many units of alcohol do
you drink on a typical day
when you are drinking?
0
1
2
3
4
Never
Monthly
or less
2-4
times
per
month
2-3
times
per
week
4+
times
per
week
1 -2
3-4
5-6
7-9
10+
Weekly
Daily
or
almost
daily
How often have you had 6 or
Less
more units if female, or 8 or
Never
than
Monthly
more if male, on a single
monthly
occasion in the last year?
Scoring:
A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.
Your
score
SCORE
Family History:
Please circle the appropriate box if your family suffer with or have had any of the following:
Heart Disease
Stroke
Diabetes
FAMILY
FAMILY
FAMILY
NHS Health Checks:
This only applies for patients aged 40-74years hold
Have you been previously offered an NHS Health Check:
If NO would you like an NHS Health Check with the Nurse?
□
□
YES
□
NO
□
Thomas Walker Surgery - Named GP
From 1 April 2015 all practices are required to allocate a named accountable GP to all patients.
Depending on your surname you will be allocated the following Partner.
Surnames A to C
Allocated Partner is Dr N Sehgal
Surnames D to H
Allocated Partner is Dr F Z Mazi Kotwal
Surnames I to O
Allocated Partner is Dr H G J Mistry
Surnames P to Z
Allocated Partner is Dr S Brackenbury
If any patient wishes at any time to change their named GP, from the Partner allocated, contact
the surgery & we can make this change.
You remain free to see any GP for your consultations.
AS A NEW PATIENT PLEASE USE THESE HELPFUL HINTS TO ENABLE YOU TO GET THE
MOST FROM YOUR CONSULTATION





Please remember you are a new patient, we have yet to get to know you and your medical
history. Eventually if you have ever been registered with another surgery in the UK, your medical
records will be sent to us, but until they arrive we need your help to be able to treat you
appropriately.
If you have never been registered with another GP surgery in the UK, please bring as much
information as you have from your previous Doctor or hospital about any illnesses you have,
treatments or operations you have had, medications that you take. Even if that information is not
in English, we may be able to find a means of having it translated.
If you already take medication, and need some more tablets or other, bring along the names of
what you take, or even the empty bottles – this information will be helpful. Remember to bring
details of when you first started on this medication and how often you take it.
Be prepared, time with any Doctor or Nurse is limited. Write down what you want to tell the
Doctor or Nurse and what you want to ask, this will help you and remind you of any issues you
want to raise.
If you think you may have difficulties understanding what the Doctor or Nurse tells you, or you
may have difficulties getting into or out of the building, then please do bring someone along with
you, to help you.
THOMAS WALKER SURGERY
Additional questionnaire for patients aged between 16-35 years.
The surgery is taking part in a national screening programme for latent tuberculosis. This is a form of TB
which usually does not cause any symptoms, but which can progress to active TB if left untreated.
Latent TB can be detected by a simple blood test.
Please could we ask that you answer a few questions to check if you are eligible for screening?
Name
Date of birth
Have you arrived in the UK in the last 5 years?
YES
If the answer is “yes” what date did
you arrive?
NO
Were you born in, or have you spent six months or more in any of the countries listed below?
YES
NO
Please add a tick against the relevant country
Afghanistan
Angola
Bangladesh
Benin
Bhutan
Botswana
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Cote D’Lvoire
Djibouti
DPR Korea
DR Congo
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gabon
Gambia
Please turn over.
Ghana
Greenland
Guinea
Guinea-Bissau
Haiti
Indonesia
India
Kenya
Kiribati
Laos PDR
Lesotho
Liberia
Madagascar
Malawi
Mali
Marshall
Mauritania
Mauritius
Micronesia
Mongolia
Mozambique
Myanmar
Namibia
Nepal
Niger
Nigeria
Pakistan
Papua New Guinea
Philippines
Nigeria
Pakistan
Papua New Guinea
Philippines
Republic of Moldova
Rwanda
Sao Tome & principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
South Sudan
Swaziland
Timor-Leste
Togo
Tuvalu
Uganda
UR Tanzania
Zambia
Zimbabwe
Have you ever been treated for tuberculosis in the past?
YES
NO
Have you ever been screened for tuberculosis before? (excluding a chest x-ray)
YES
NO
Thank you for completing this questionnaire if you are eligible for screening we will send you a letter
inviting you for a blood test to screen for TB.
Ethnic Background and Language
We want to ensure that we are providing an appropriate and accessible service for the whole community.
In order to help us, please could you take a moment to complete the most applicable ethnic background box and complete
the language section below:
Thank You for your time.
(Please specify)…………………
ETHNICITY:
White/European

























British
English
Scottish
Welsh
Irish
Greek
Turkish
Italian
Irish Traveller
Gypsy/Romany
Roma
Polish
Baltic States
Russian States
Kosovan
Albanian
Bosnian
Croatian
Serbian
Lithuanian
Latvian
Romanian
Portuguese
Czech
Slovak
 Any other White background
/European
Mixed
 White and Black Caribbean
 White and Black African
 White and Black African
Asian or Asian British




Indian or British Indian
Pakistani or British Pakistani
Bangladeshi or British Bangladeshi
Any other Asian background
(please specify)…………….
Black or Black British
 Caribbean
 African
 Any other Black background
(please specify)……………
Chinese or Other Ethnic Group
 Chinese
 Iranian
 Iraqi
 Kurdish
Any other
(please specify)……………..
LANGUAGE:
 Interpreter needed?
YES/NO
If Yes which language….…………………
 Any other mixed background
(please specify)…………….
Your emergency care summary
Dear Patient
Summary Care Record – your emergency care summary
The NHS in England is introducing the Summary Care Record, which will be used in emergency care.
The record will contain information about any medicines you are taking, allergies you suffer from and any
bad reactions to medicines you have had to ensure those caring for you have enough information to treat
you safely.
Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere
in England, but they will ask your permission before they look at it. This means that if you have an
accident or become ill, the doctors treating you will have immediate access to important information about
your health.
As a patient you have a choice:
• Yes I would like a Summary Care Record – you do not need to do anything and a Summary Care
Record will be created for you.
• No I do not want a Summary Care Record – Please ask for an opt-out form at reception.
If you need more time to make your choice you should let your GP Practice know.
For more information talk to the Patient Advice and Liaison Service (PALS) (tel: 01733 776283), visit the
NHS Peterborough website (www.peterborough.nhs.uk), telephone the dedicated NHS Summary Care
Record Information Line on 0300 123 3020, or visit their website www.nhscarerecords.nhs.uk, or
contact your GP practice staff.
Additional copies of the opt-out form can be collected from the GP practice, printed from the website
www.nhscarerecords.nhs.uk or requested from the dedicated NHS Summary Care Record Information
Line on 0300 123 3020.
You can choose not to have a Summary Care Record and you can change your mind at any time
by informing your GP practice.
If you do nothing we will assume that you are happy with these changes and create a Summary Care
Record for you. Children under 16 will automatically have a Summary Care Record created for them
unless their parent or guardian chooses to opt them out. 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 this information available to
them.
Document1,
Form from Geeta Pankhania, reviewed PRIMIS 23/04/2010