GRANTA MEDICAL PRACTICES Sawston Medical Centre/Linton Health Centre

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Personal Details Title: Mr / Mrs / Miss/ Ms / Other Please circle as appropriate Surname:

First Names:

Date of Birth

Male / Female (Please circle)

Address Including Postcode

Marital Status:

Telephone:

Home:

Work: Mobile:

Email Address Skype address

Can we text you appointment reminders, and test results: Yes / No

Occupation

First Language

Next of Kin Relationship

Next of Kin Tel No

Carer/Cared for:

Are you an informal (ie unpaid) Carer?

Yes / No

Do you have a family carer? (a family carer can include a friend, somebody not paid) Yes / No

Name Carer Tel No:

Ethnicity: White – British Indian White & Black

African Irish Pakistani White & Black Asian

Other White background

Bangladeshi African

Chinese Caribbean

Religion

Other (please state)

Health Promotion Height:

Weight Waist Circumference (cm)

Smoking Status Please circle as appropriate

Never Smoked

Ex Smoker

Smoker

How Many Cigarettes a day: If you are interested in stopping smoking please book an appointment with one of our trained smoking cessation facilitators

Do you take regular exercise?

Yes / No Mins per week

Previous Medical History (Please circle as appropriate)

Asthma

Chronic Obstructive Pulmonary Disease

(COPD)

Diabetes

Hypertension

(Raised Blood Pressure

Heart Problems

Epilepsy

Other: (Please specify)

Allergies Allergy to medication

(please specify)

Allergy to Animals

(please specify)

Other Allergies

(please specify)

GRANTA MEDICAL PRACTICES Sawston Medical Centre/Linton Health Centre

C:\Users\Alantr\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\T5EBXCPF\2016 New patient questionnaireV3.doc

Medication Please list any medications you are currently taking: If you take regular medication please make an appointment to see one of the doctors, bringing with you a repeat medication slip from your previous surgery. You will need this appointment before we can issue

you with any more medication Family History (Please circle as appropriate)

Relation

Asthma Yes / No Cancer Yes / No Diabetes Yes / No Heart Attack (Under 60) Yes / No Heart Attack (Over 60) Yes / No Heart Disease Yes / No High Blood Pressure Yes / No Stroke / TIA Yes / No

Alcohol Consumption (Please circle as appropriate)

If your score is 5 or more you will be offered further intervention

Online access to records is available to Patients aged 16 and over, Proxy access for patients aged 0 to 11 inclusive only

Online Access to Records

I wish to have access to the following online services (please tick all that apply): Booking appointments Requesting repeat prescriptions Accessing my medical record

I wish to access my medical record online and understand and agree with each statement (tick)

I have read and understood the information leaflet provided by the practice

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Signature Date

Practice use only (scan to patient record) At least two documents are required to verify identification, at least

one needs to contain a photograph of the patient. Acceptable Documentation:

Document Seen Tick as applicable

Number ID Verified Initials

• Passport • Driving

License

• Bank Statement

Family d

octo

r services registratio

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MS1

Patient’s d

etailsPlease co

mp

lete in B

LOC

K C

APITA

LS and

tick as ap

pro

priate

Mr

Mrs

Miss

Ms

Surn

ame

Date o

f birth

First nam

es

NH

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us su

rnam

e/sN

o.M

aleFem

aleTo

wn

and

cou

ntry

of b

irth

Ho

me ad

dress

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de

Teleph

on

e nu

mb

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Please help

us trace yo

ur p

reviou

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ical record

s by p

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the fo

llow

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info

rmatio

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ur p

reviou

s add

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KN

ame o

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us d

octo

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Ad

dress o

f previo

us d

octo

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If you

are from

abro

adYo

ur first U

K ad

dress w

here reg

istered w

ith a G

P

If previo

usly resid

ent in

UK

,D

ate you

first came

date o

f leaving

to live in

UK

If you

are return

ing

from

the A

rmed

Forces

Ad

dress b

efore en

listing

Service or

Enlistm

ent

Person

nel n

um

ber

date

If you

are registerin

g a ch

ild u

nd

er 5

I wish

the ch

ild ab

ove to

be reg

istered w

ith th

e do

ctor n

amed

overleaf fo

r Ch

ild H

ealth Su

rveillance

If you

need

you

r do

ctor to

disp

ense m

edicin

es and

app

liances*

I live mo

re than

1 mile in

a straigh

t line fro

m th

e nearest ch

emist

I wo

uld

have serio

us d

ifficulty in

gettin

g th

em fro

m a ch

emist

Sign

ature o

f Patient

Sign

ature o

n b

ehalf o

f patien

tD

ate________/_________/_________

Please see overleaf re: O

rgan

do

natio

n

*No

t all do

ctors are

auth

orised

to

disp

ense m

edicin

es

Versio

n 01/02

GM

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Family d

octo

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n

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NH

S Org

an D

on

or reg

istration

I want to register m

y details on the NH

S Organ D

onor Register as someone w

hose organs/tissue may be used for transplantation

after my death. Please tick th

e bo

xes that ap

ply.

An

y of m

y org

ans an

d tissu

e or

Kid

neys

Heart

LiverC

orn

easLu

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sPan

creas An

y part o

f my b

od

y

Sign

ature co

nfirm

ing

my ag

reemen

t to o

rgan

/tissue d

on

ation

D

ate ________/________/________

For m

ore in

form

ation

, please ask at recep

tion

for an

info

rmatio

n leaflet o

r visit the w

ebsite

ww

w.u

ktransp

lant.o

rg.u

k, or call 0300 123 23 23.

NH

S Blo

od

Do

no

r registratio

nI w

ould like to join the NH

S Blood Donor Register as som

eone who m

ay be contacted and would be prepared to donate blood.

Tick here if yo

u h

ave given

blo

od

in th

e last 3 yearsSig

natu

re con

firmin

g co

nsen

t to in

clusio

n o

n th

e NH

S Blo

od

Do

no

r Reg

ister Date ________/________/________

For m

ore in

form

ation

, please ask fo

r the leaflet o

n jo

inin

g th

e NH

S Blo

od

Do

no

r Reg

isterM

y preferred

add

ress for d

on

ation

is: (on

ly if differen

t from

abo

ve, e.g. yo

ur p

lace of w

ork)

Postco

de:

To b

e com

pleted

by th

e do

ctor

Do

ctors N

ame

HA

Co

de

I have accep

ted th

is patien

t for g

eneral m

edical services

For th

e pro

vision

of co

ntracep

tive services

I have accepted this patient for general medical services on behalf of the doctor nam

ed below w

ho is a mem

ber of this practice

Do

ctors N

ame,if d

ifferent fro

m ab

ove

HA

Co

de

I am o

n th

e HA

CH

S list and

will p

rovid

e Ch

ild H

ealth Su

rveillance to

this p

atient o

r

I have accep

ted th

is patien

t on

beh

alf of th

e do

ctor n

amed

belo

w, w

ho

is a mem

ber o

f this p

ractice and

is on

the

HA

CH

S list and

will p

rovid

e Ch

ild H

ealth Su

rveillance to

this p

atient.

Do

ctors N

ame, if d

ifferent fro

m ab

ove

HA

Co

de

I will d

ispen

se med

icines/ap

plian

ces to th

is patien

t sub

ject to H

ealth A

uth

ority’s A

pp

roval

I am claim

ing

rural p

ractice paym

ent fo

r this p

atient.

Distan

ce in m

iles betw

een m

y patien

t’s ho

me ad

dress an

d m

y main

surg

ery is

I declare to

the b

est of m

y belief th

is info

rmatio

n is co

rrect and

I claim th

e app

rop

riate paym

ent as set o

ut in

the

Statemen

t of Fees an

d A

llow

ances. A

n au

dit trail is availab

le at the p

ractice for in

spectio

n b

y the H

A’s au

tho

risedo

fficers and

aud

itors ap

po

inted

by th

e Au

dit C

om

missio

n.

Practice Stamp

Au

tho

rised Sig

natu

re

Nam

eD

ate _______/_______/_______

HA

use

on

lyPatien

t registered

for

GM

SC

HS D

ispen

sing

Ru

ral Practice

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