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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
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
nG
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
SPrevio
us su
rnam
e/sN
o.M
aleFem
aleTo
wn
and
cou
ntry
of b
irth
Ho
me ad
dress
Postco
de
Teleph
on
e nu
mb
er
Please help
us trace yo
ur p
reviou
s med
ical record
s by p
rovid
ing
the fo
llow
ing
info
rmatio
nYo
ur p
reviou
s add
ress in U
KN
ame o
f previo
us d
octo
r wh
ile at that ad
dress
Ad
dress o
f previo
us d
octo
r
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
S1-JU
L12_GM
S 1 17/07/2012 13:15 P
age 1
Family d
octo
r services registratio
n
GM
S1
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
ng
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
GM
S1-JU
L12_GM
S 1 17/07/2012 13:15 P
age 2