Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Adult registration pack
Document related concepts
no text concepts found
Transcript
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
