New Patient Registration Form - For children up to 16 years of age Thank you for applying to join Uppingham Surgery. We would like to gather some information about your child 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 the best possible care. Please supply the child’s birth certificate or a form of Identification with the completed form, a photographic form of ID (such as passport) 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 AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 GPSchool*School that child is registered withAre you looking after someone else's child?* Yes No A child who is being looked after by their local authority is known as a child in care. They might be living: with foster parents, at home with their parents under the supervision of social services or in residential children's homes.If Yes, under what arrangements:* Section 20-Voluntary Care Interim Care Order Care Order Child arragement order/Residence Order Special Guardianship Order Placed for adoption Private arrangement/ Private Fostering/ informal agreement (please note you have a duty to notify social care of this arrangement If you are applying on behalf of your child or a child who is in foster care/ residential care/ Kinship care/ or who is not your child:Who has legal responsibility?You as the parentOtherPlease specifyWho can consent for the medical treatment for the child?You as the parentOtherPlease specifyI would describe the child’s ethnic group as (please tick)White BritishWhite IrishBlack CaribbeanBlack AfricanIndianPakistaniChineseWhite + Black CaribbeanWhite + AfricanWhite + AsianOtherPlease specifyMain Language spoken (e.g English)Is the child a dependant of a current serving member of British Armed Forces?*YesNo Is the contact named below authorised to discuss the child’s medical record with us?*YesNoNext 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.Is the child looked after or supported by someone who they couldn’t manage without?*YesNoIf yes, what is their name and contact number?Do you consent for the carer to be informed about the child’s medical care?YesNoDoes the child look after or support someone who couldn’t manage without them?*YesNoIf yes, do they look after someone who is a patient of Uppingham Surgery?YesNoDon't KnowIf yes, what is their name?Are they aRelativeFriendNeighbour Medical Details In order to continue to receive repeat medications you’ll need to make a new patient health check appointment for the child and bring in their 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 child’s repeat medication list found on the right hand side of a printed prescription.Is the child allergic to any medicines?*YesNoPlease specifyPlease listList other allergies / intolerances (i.e. nuts, gluten, pollen, animal hair or certain foods. Please mark “none” if the child has no other allergies that you know of)Does the child have any disabilities, illnesses or accessibility needs?Does the child have any disabilities, illnesses or accessibility needs? I.e. needing to be seen in ground floor consulting rooms or use of a specific communication device such as a hearing aid? If yes, please tell us how we can support their needs.The Accessible Information Standard (AIS)For further information please visit https://www.england.nhs.uk/ourwork/accessibleinfo Family HistoryDoes the child a have 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 StatusDoes the child smoke?YesNoIf Yes, what do you primarily smoke:*Cigarette smokerRolls own cigaretteCigar smokerPipe smokerHow many does the child smoke a day?Would you like advice on quitting?YesNoIs the child an ex-smokerYesNoWhen did they quit?How many did you used to smoke a day?Please record any additional information about your child that you think is important for us to knowNHS Organ Donor registration Select All Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming consent to organ donation I want to register my child’s details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after their 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 child’s registration we will contact you to clarify any issues, but once your details have been entered into our computerized records… On-line Services It may be possible for the child or parent/carer to access particular patient record services online. Please ask reception if you would like more details. New Patient Health-check Your child 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.