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Kingsholm Surgery New Patient Health Questionnaire Name: …………………………………………………………………………………………. Address: ………………………………………………………………………………………... Postcode……………………………. Date of Birth………………………………………….. Telephone Home………………………….Mobile…………………………………………… Can we leave messages on your answer machine if needed? Yes……………………….No………………………………………………………………….. Marital Status…………………………………………………………………………………... Occupation……………………………………………………………………………………... What is your first language? (eg English)……………………………………………………… Ethnic Origin (Tick as Applicable) WHITE British ………………………………………………… Irish …………………………………………………… Irish Traveller ………………………………………… Any other White Background (please state) ………..... BLACK OR BLACK BRITISH Caribbean ……………………………………………... African ………………………………………………… Any other Black Background (please state) …………... OTHER ETHNIC GROUP Chinese ………………………………………………... Any other Ethnic Group (please state which) ………… MIXED Black and other mixed background …………………… Black/White origin ……………………………………. Asian/White origin ……………………………………. ASIAN OR ASIAN BRITISH Indian ………………………………………………….. Pakistani ………………………………………………. Bangladeshi …………………………………………… Any other Asian background (please state)……………. 9S10 9S11 9SI 9S12 9S2 9S3 9S4 9S9 9SA 9S5 9S51 9SB2 9S6 9S7 9S8 9SH Previous Doctor………………………………………………………………………………… Past Medical History- list any operations or serious illnesses and their dates ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………. Medciation……………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………….. Allergies……………………………………………………………………………………....... Family History-please circle Heart Disease Diabetes Stroke Asthma Any other hereditary illnesses………………………………………………………………… Smoking Have you ever been a smoker? Yes No Do you smoke now? Yes No If yes, how many per day? If you are an ex-smoker , when did you give up? Alcohol, please fill in form below. Last smear date (women only)…………………………………………..................................... Height……………………………..Weight……………………………………………………. Are you a carer? Yes No If yes, what is your relationship with the person being cared for?............................................................................................................................................... ...................................................................................................................... This is one unit of alcohol… …and each of these is more than one unit AUDIT – C 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? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Scoring system 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+ Never Less than monthly Weekly Daily or almost daily Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. Monthly Your score SCORE Score from AUDIT- C (other side/above) SCORE Remaining AUDIT questions Questions How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Scoring system 0 1 Never Less than monthly Never Less than monthly Never Less than monthly Never Less than monthly Never Less than monthly Have you or somebody else been injured as a result of your drinking? No Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence 2 Monthly Monthly Monthly Monthly Monthly Yes, but not in the last year Yes, but not in the last year 3 4 Weekly Daily or almost daily Weekly Daily or almost daily Weekly Daily or almost daily Weekly Daily or almost daily Weekly Daily or almost daily Your score Yes, during the last year Yes, during the last year TOTAL KINGSHOLM SURGERY PATIENT MEDICAL RECORD DATA SHARING & CONFIDENTIALITY The development of computerised clinical records has widened the variety of functions that it can be used for. Kingsholm Surgery is obligated to provide information to and for the NHS, however the patient still has the choice to Opt Out if desired. Summary Care Records (SCR). The SCR at the moment only holds demographics and basic patient data such as medications and allergies. This information is available to other facilities such as Gloucester Royal Hospital and Out of Hours. The depth of information available on the SCR will grow as the system is developed. It is important for Health Care Professionals to have access to this data. The Health and Social Care Information Centre (HSCIC) has been given permission by the NHS to automatically collect data about you from the surgery clinical data system. Note that this is NOT the same as the SCR upload. If you opted out of the SCR, that will not have any effect on the HSCIC data collection. HCSIC collects your date of birth, NHS Number and gender. It then collects information about family history, diagnosis, referrals, investigations, results and medication. This is then to be used for research purposes, gathering data for public health monitoring etc. Sharing In / Sharing Out. Kingsholm Surgery uses System One Clinical System. This is a hosted system and is quickly becoming the system of choice for a large selection of clinical care in the NHS. The database is centrally stored and means that in addition to the two processes above, data could be shared between other System One users. Kingsholm patients have the option for their data to be seen at other NHS locations if the situation occurs; i.e. if in another part of the country and you end up needing clinical assistance, if the organisation was a System One user, then the clinicians would be able to view your data from Kingsholm and use it to help make decisions about your care. Locally System One is used by the District Nurses and by the Community Hospitals (Tewkesbury Hospital, The Dilke Memorial Hospital etc.). You can choose to allow data sharing in 2 different ways. “Sharing Out” allows other NHS organisations using System One to see the data that Kingsholm Surgery holds on you. “Sharing In” allows Kingsholm Surgery to see the data held on you by other System One users. We think that sharing such data will improve your care and communication within NHS organisations. Please complete the form overleaf and return to reception so we know your choices. The Surgery will then mark your notes so that they will not be uploaded. OPTING OUT OF DATA SHARING NAME……………………………………………………………………………………… ADDRESS…………………………………………………………………………………. ……………………………………………………………………………………………… I wish to Opt Out from the following clinical data sharing functions (please tick): Summary Care Record (Read Code = XaXj6) Health and Social Care Information Centre – Data extraction (Read Code = XaZ89 / XaaVL) System One Sharing In System One Sharing Out SIGNATURE ………………………………………………………………………………….. DATE ………………………………………………………………………………………….. Please note that if you change your mind and wish data to be shared, you must write to your clinician requesting to Opt In.
