New Patient Registration Form- Adult Thank you for applying to join Uppingham Surgery. We would like to gather some information about you and ask that you fill in the following questionnaire. You don’t have to supply answers to all of the questions but what you do fill in will help us give you the best possible care. Please supply two forms of Identification with your completed form, a photographic form of ID (such as passport or driving license) and proof of your home address (such as a recent bank statement or document relating to your new home). Step 1 of 6 16% Patient's DetailsTitle*MrMrsMissMsOtherPrefer not to sayName* First Names Last Name Previous SurnamesDate of Birth* Date Format: DD slash MM slash YYYY Gender*MaleFemaleIntermediateUnspecifiedNHS Number (If known)Email* Town and Country of Birth*Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home telephone number*Preferred Contact Number HomeYesNoWork telephone numberPreferred Contact Number WorkYesNoMobile numberPreferred Contact Number MobileYesNoPlease help us trace your previous medical records by providing the following information Your previous address in UK*Previous address and PostcodeName of previous doctor while at that address*Previous GP Details*Name and Address of Previous GP(for women only) Have you had a cervical smear?YesNoIf Yes please state where, when and the result if possibleIf you are from abroad Your first UK address where registered with a GPIf previous resident in UK, date of leaving Date Format: DD slash MM slash YYYY Date you first came to live in UK (DD/MM/YYYY) Date Format: DD dash MM dash YYYY Marital Status*SingleMarriedDivorcedWidowedWhich Ethnic group do you feel you belong to?White BritishWhite IrishBlack CaribbeanBlack AfricanIndianPakistaniChineseWhite + Black CaribbeanWhite + AfricanWhite + AsianOtherPlease specifyMain Language spoken (e.g English)Have you ever been in the employ of the Armed Forces?YesNoIf you are returning from the armed forces Address before enlistingService or personnel numberEnlistment date (DD/MM/YYYY) Date Format: DD dash MM dash YYYY Leaving date (DD/MM/YYYY) Date Format: DD dash MM dash YYYY Are you a dependent of a current serving member of the British Armed Forces?*YesNoAre you a military veteran?*YesNo Next of Kin/Emergency Contact Name*Next of Kin/Emergency Contact relationship to you*Next of Kin/Emergency Contact telephone number*Next of Kin/Emergency Contact address (if different to yours)Data SharingSummary Care RecordSummary Care Record (SCR) Your SCR is an electronic summary of key medical information taken from your GP medical record. If you need healthcare away from your usual doctor’s surgery, your enhanced SCR will provide those looking after you with key information to help them give you better and quicker care. Please refer to ‘What is a Summary Care Record’ document: More information can be found by visiting: https://digital.nhs.uk/ Tick this box if you wish to have an enhanced SCR with core and additional information (recommended) Tick this box if wish to opt-out the child of the SCR Medical Interoperability Gateway (MIG)The MIG enables secure sharing of relevant medical information from your GP record with other healthcare professionals who are providing you with direct care, even if they are not using the same electronic records system. At point of care you will be asked if you consent to the care service seeing essential elements of your record. More information can be found by visiting: https://healthcaregateway.co.uk/?s=products Tick this box if you wish to opt-out of the MIG data sharing Risk Stratification PreferencesRisk stratification is the process of identifying the relative risk of patients in a population by analysing their medical history. It's a key enabler for improving the quality of care delivered by the NHS. Uppingham Surgery is taking part in the Risk Stratification programme and will be uploading patient identifiable data for analysis. Patient identifiable information will only be viewable at GP practice level. Any NHS organisation external to the practice using risk stratification will only see anonymised data. For more information please visit our website at www.uppinghamsurgery.nhs.uk Tick this box if you wish to opt-out of the Risk Stratification programme Enhanced Data Sharing Module (EDSM)Uppingham Surgery use a clinical computer system called SystmOne to record your medical information. With your consent, you can allow your full GP record to be shared with other healthcare services that are providing care for you and who also use SystmOne. These other services will always ask consent to view your record. For more information please visit our website at email@example.com Tick this box if you wish to opt-out of the Enhanced Data Sharing Module *Do you consent to receive the following types of communication (if offered) from Uppingham Surgery?* Email Mobile phone text messages Answering machinemessages Carers Information A carer is a friend or family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided. A carer can receive Carers Allowance, but not a wage and the care they are giving will significantly affect their own life.Are you looked after by someone whose support you could not manage without?*YesNoWhat is their name and contact number?Do you consent for your carer to be informed about your medical care?YesNoDo you look after or support someone who could not manage without you?*YesNoIf yes, do you look after someone who is a patient of Uppingham Surgery?YesNoDon't KnowWhat is their name?Are they aRelativeFriendNeighbour Medical Details In order to continue to receive your repeat medications you’ll need to make a new patient health check appointment and bring in your last repeat prescription. (Please note, certain medications will require an appointment with the GP before they can be prescribed) Please allow plenty of time to organise repeats. Please provide us with your repeat medication list found on the right hand side or a printed prescription.Are you allergic to any medicines?*YesNoPlease specifyPlease list any other allergies/intolerances (i.e nuts, gluten, pollen, animal hair or certain foods). Mark 'none' if you have no other allergies that you know ofThe Accessible Information Standard (AIS)For further information please visit https://www.england.nhs.uk/ourwork/accessibleinfo Family HistoryDo you have a family history of any of the following? High blood pressure Ischaemic Heart Disease Diagnosed aged >60 yrs Ischaemic Heart Disease Diagnosed aged <60 yrs Raised Cholesterol Stroke/CVA Asthma DVT/Pulmonary embolism Breast Cancer Any Cancer specify type Thyroid disorder Epilepsy Osteoporosis Please state which family member has High blood pressurePlease state which family member has Ischaemic Heart Disease Diagnosed aged >60 yrsIschaemic Heart Disease Diagnosed aged <60 yrsPlease state which family member has Raised CholesterolPlease state which family member has Stroke/CVAPlease state which family member has AsthmaPlease state which family member has DVT/Pulmonary embolismPlease state which family member has Breast cancerPlease state which family member has Thyroid disorderPlease state which family member has EpilepsyPlease state which family member has OsteoporosisPlease state which typePlease state which family member has Any CancerSmoking StatusSmoking Status*Never SmokedEx SmokerCigarette smokerRolls own cigaretteCigar smokerPipe smokerHow many do you smoke a day?Would you like advice on quitting?YesNoWhen did you quit?How many did you used to smoke a day?Please tell us your height, weight and waist circumferenceHeightFtCmsWeightStKgsWaist circumferenceInchsCmsAlcohol Consumption This is one unit of alcohol And each one of these, is more than one unit How often do you have a drink containing alcohol?*NeverMonthly or less2-4 times per month2-3 times per week4+ times per weekHow many standard alcoholic drinks do you have on a typical day when you are drinking?1-23-45-67-910+How often have you had 6 or more standard drinks on one occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyPlease record any additional information about you that you think is important for us to knowNHS Organ Donor registration Select All Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming consent to organ donation I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply. For more information, please visit the website www.uktransplant.org.uk or call 0300 123 23 23Signed*Date* Date Format: DD slash MM slash YYYY Signed on behalf of patient (if applicable)Signed on behalf of patient (if applicable) (e.g. for minors under 16 years old, adults lacking capacity) If there are any problems with your registration we’ll contact you to clarify any issues, but once your details have been entered into our computerized records… On-line Services You will be able to register with our on-line service and access appointments, prescriptions and some sections of your own medical record via the internet. All of the details that you need for this are available by requesting to be registered at reception. New Patient Health-check You will be eligible for a new patient health-check with a Practice Nurse/Health Care Assistant. Contact reception if you should like to take this up.