Download New Patient Health Questionnaire

OVERSEAL SURGERY
NEW PATIENT REGISTRATION FORM
Please complete this questionnaire as fully as possible. A separate questionnaire must be
completed for each family member who wishes to register with us. When you return your
application form to the surgery please provide 2 forms of ID, preferably including a current
passport/photo driving licence. If you have recently arrived in this country please bring your
passport to confirm your date of birth and entitlement to NHS treatment.
All the information you provide will be treated in the strictest confidence.
Full Name:
DOB:
Address:
Tel. No:
Mobile:
Post Code:
Height:
Weight:
Do you smoke?
Have you ever smoked?
If so when did you stop?
What is your first spoken language?
Do you have any sensitivities or
allergies?
Last BP reading (if known)
Email:
cm/ft
Kg/stone
Y/N
Y/N
Next of Kin Details
Name:
Tel: No.
Relationship:
Mobile:
Disabilities
Do you have any disabilities?
Y/N (if yes please state)
Do you need assistance/special
requirements to access the premises?
Y/N (if yes please state)
Do you or your carer have any
communication/information needs
relating to a disability, impairment or
sensory loss?
Y/N (if yes please state)
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Medical History:
Do you, or have you ever suffered from any of the following? (Please circle)
Diabetes Mellitus
Depression/mental health
problems
Under Active/Over Active
Thyroid
Dementia
Asthma
Coronary Heart
Disease/Heart
Attack/Stroke
Epilepsy
Parkinson’s Disease
Cancer
High Blood Pressure
Chronic Obstructive
Pulmonary Disease (COPD)
Chronic Kidney Disease (CKD)
Medication:
If you are currently on repeat medication please provide a current medication list/repeat
prescription form.
Carers
Do you have a carer who assists you with any aspect of your life? This can include family
members: Yes / No
Carers Name: ………………………………………………………………Tel No.: …………………………………
Are you a carer for a patient registered with us? Y/N
If you are a military veteran would you like this information recorded on your patient
record? Y/N (Read code Xa8Da)
All our patients have a Named Accountable GP, if you would like to know who this is or to
request a specific GP please contact us.
Is there anything further you feel we should be aware of e.g. any religious or cultural needs,
if you require translation/interpretation services, any phobias you have, or any information
that you would find useful from us?
…………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………….
If you do not wish us to contact you via text messaging please inform reception so that this
can be entered onto your records.
Date of completion of this form: ………………………………………………………………………….
YOU ALSO NEED TO COMPLETE A GMS1 FORM WHICH IS AVAILABLE FROM
RECEPTION OR TO DOWNLOAD FROM OUR WEBSITE
WWW.OVERSEALSURGERY.CO.UK BEFORE YOU CAN BE REGISTERED.
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On-Line Services
If you would like to register for on-line services which will enable you to booking/cancel appointments,
order repeat medications, view your Summary Care Record or to gain access to your Detailed Coded
Record please see our website or contact our Reception Team.
Consent to Share
Unless you inform us otherwise we will assume that we have your permission to share your
information with other professionals involved directly in your care. You have the right to change
your decision on this at any time.
Patient Participation Group
Would you like to have a say about the services we provide? We meet quarterly to discuss any
relevant issues, so if you feel that you are able to be a voice for our patients please contact
our Practice Manager on 01283 760595 for more information or visit our website at
www.oversealsurgery.co.uk.
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
FOR OFFICE USE ONLY: FORMS OF ID SEEN: ………………………………………………………………………..
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ALCOHOL AUDIT
1 drink = half pint beer/lager, 1 glass normal glass wine or 1 measured shot spirits
1. How often do you have a drink containing alcohol?
Never
Monthly or less
2 or 4 times
a month
(0)
(1)
(2)
2 to 3 times
a week
(3)
4 or more times
a week
(4)
2. How many standard drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
(0)
(1)
(2)
(3)
(4)
3. How often do you have 6 or more standard drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
(0)
(1)
(2)
(3)
Daily or almost daily
(4)
4. How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
(0)
(1)
(2)
(3)
(4)
5. How often during the last year have you failed to do what was normally expected from you because of your
drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
(0)
(1)
(2)
(3)
(4)
6. How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy
drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
(0)
(1)
(2)
(3)
(4)
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
(0)
(1)
(2)
(3)
(4)
8. How often during the last year have you been unable to remember what happened the night before because you had
been drinking?
Never
Less than monthly
Monthly
Weekly
Daily of almost daily
(0)
(1)
(2)
(3)
(4)
9. Have you or someone else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes during the last year
(0)
(2)
(4)
10. Has a relative or friend, doctor or other health professional worker been concerned about your drinking or suggested
you cut down?
No
Yes, but not in the last year
Yes during the last year
(0)
(2)
(4)
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