Patient Questionnaire for Adults

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this Practice and that you live within our Practice boundary. Sending this form does NOT guarantee or imply that you will be accepted onto the Practice register. Please allow up to five working days for us to process your registration.

Last Updated: 15/05/2022

Your Contact Details

Title *

Name and Surname *

Date of Birth *

Previous Surname

Home Telephone Number

Mobile Number

Email Address

Next of Kin

(or who to contact in an emergency)

Full Name *

Telephone Number *

Relationship to Me *

Contacting You

To preserve resources and to be environmentally friendly, we will contact you by SMS or email, unless you specifically state 'No' in which case we will write to you

What is your preferred method of contact? *

SMS (Text Message)

Other

Telephone Call Recording - all incoming and outgoing calls are recorded. This is our standard operational procedure. If you do not consent to your telephone call being recorded we will NOT be able to provide medical services to you. *

Yes No

Other preferred method of communication

Do you agree that you may be contacted via email with invitations to health reviews and services, advice about your health and appointment reminders? *

Yes No

Do you agree that you may be contacted via SMS (Text Message) with invitations to health reviews and services, advice about your health and appointment reminders? *

Yes No

Communication Needs

The Accessible Information Standard aims to ensure patients and/or their carers who have a disability or sensory loss can receive, access and understand information in a suitable format e.g. large print, braille, email or from a British Sign Language interpreter. Individuals most likely to be affected by the Standard are those who have sight and/or hearing loss and people with a learning disability (this list is not exhaustive)

What is your main spoken language? *

Do you have specific communication needs? *

Yes No

Tell us about your vision - Normal / Impaired vision / Registered partially sighted / Registered blind / Wears glasses / Wears contact lenses

Do you wear hearing aids?

Yes No

Do you need an interpreter?

Yes No

Do you have a learning disability?

Yes No

What other communication support might you need?

Information About You

Collecting this information helps result in better health outcomes and helps prevent health care inequalities.,

Medical Information

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Women

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when and the result

Carers

Do you have a carer? Are you cared for by a relative/friend? *

Yes No

If yes please give details

Do you care for someone? *

Yes No

If yes please give details - including whether you are an occupational carer

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking? *

Yes No

Alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

( Women) How often have you had 6 or more units, / (Men) How often have you had 8 or more units, on a single occasion in the last year? *

Sharing Your Health Record

With the development of information technology, the NHS will increasingly be sharing key information from your GP Medical Record with Out of Hours GP Services, Hospital A&E Units, Community Hospitals, Community Nurses, all of who may be looking after you at various points in your life. Sharing your information can improve the quality and safety of care you receive and in some cases can be vital in making life-saving decisions about your treatment.

Do you consent to the sharing of data by your GP Practice with other NHS organisations that may care for you? *

Yes No

Do you consent to the GP Practice viewing data that is recorded at other NHS organisations and care services that care for you? *

Yes No

NHS Summary Care Record (SCR)

The SCR was introduced many years ago to help deliver better and safer healthcare. It contains basic information about and allergies you may have, unexpected reactions to medications and any prescriptions you have recently received. The intention is to allow Hospital A&E departments and Out of Hours health services to give you safe, timely and effective treatment. Over time, health professionals treating you may add details about your health to the SCR with your consent.

Please tick ONE option for the content of your SCR *

I consent for medication, allergies and adverse reactions only

I consent for medication, allergies and adverse reactions and additional information

I DO NOT want a Summary Care Record and I understand the risks involved with this decision.

Signature

Relationship to the patient

Parent

Legal Guardian

Lasting power of attorney for health & welfare (provide copy to surgery via email)

Signature *

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; sign the form above and provide your details below:

Date *

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Patient Questionnaire for Adults

Further Information