New Patient Registration Form 			       Please complete all pages in full using block capitals

Named accountable GP: 

1. Background Details	
Contact Details	
NHS Number		If you have had a previous GP then you will find this on letters/prescriptions or at www.nhs.uk/find-nhs-number	
	I do not know my NHS number 	
Full Name		
Previous Surname (i.e. Maiden Name)		Title	 Mr   Mrs   Miss   Ms   Dr	
Gender		Date of Birth		
Which of the following best describes how you think of yourself?	 Non-binary       Female         Male          Prefer not to say        Unable to answer	
Is your gender the same as the sex you were assigned at birth?	 Yes
 No	Prefer not to say
Unable to answer	
Town & Country of Birth 	(If London, please include Borough)

Address		Home Telephone		
		Work Telephone		
Previous Address		
Mobile Telephone	I consent to be contacted* by SMS on this number: 	
Email	I consent to be contacted* by email at this address:	
Next of Kin	Name:                                                Tel:                                  Relationship:	
Family Registered With Us		
Has the patient been registered in the NHS before? 	 Yes 	 No
If no please state date entered UK:      
If previously resident in UK, date of leaving:                                   Date of return: 	
 * It is your responsibility to keep us updated with any changes to your telephone number, email & postal address.

Other Details	
Previous GP	Name:                                                
Address:	
Employment	 Employed 
 Self-employed	 Student
 Unemployed	 House husband 
 House wife	 Carer
 Retired	
Occupation		If retired, previous occupation:	
Ethnicity	 White (UK)
 White (Irish) 
 White (Other) 	 Black Caribbean
 Black African
 Black Other	 Bangladeshi
 Indian 
 Pakistani	 Chinese
 Other	
Housing	 Nursing Home
 Homeless
	 Residential Home 
 Sheltered Home
	 Housebound 
 Refugee
	 Asylum Seeker
	
Overseas Visitor	 Yes	 European Health Insurance Card Held (please bring details with you)	
Armed Forces	 Military Veteran	 Family member 			
If returning from the Armed Forces	Address before enlisting		
	Enlistment date		Leaving date		
	Service/Personnel number		
Communication Needs	
Language	What is your main spoken language?
Do you need an interpreter?                         Yes         No	
Communication
	Do you have any communication needs?     Yes         No (If Yes please specify below)	
	 Hearing aid
 Lip reading	 Large print
 Braille	 British Sign Language
 Makaton Sign Language     Guide dog	
Learning disability 	Do you have a Learning Disability?                   Yes         No
(If Yes please request a Learning Disability Screening Tool form)	
* If you need any help communicating with us e.g. if you use British Sign Language or you require information in large print or easy read, please let us know.

Carer Details	
Are you a carer?	 Yes – Informal / Unpaid Carer	 Yes – Occupational / Paid Carer	 No	
Do you have a carer?	 Yes    	Name*:	Tel:	Relationship:	
* Only add carer’s details if they give their consent to have these details stored on your medical record

2. Medical History	
Medical History	
Have you suffered from any of the following conditions?	
 Asthma
 COPD
 Epilepsy	 Heart Disease
 Heart Failure
 High Blood Pressure	 Diabetes
 Kidney Disease
 Stroke	 Depression
 Underactive Thyroid
 Cancer- Type:	
Any other conditions, operations or hospital admission details:

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

	

Family History	
Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent
	
 Asthma:
 COPD:
 Epilepsy:
 Diabetes:
 Kidney Disease:
 Liver Disease:	 Heart Disease:
 Stroke:
 Blood Pressure:
 Depression:
 Thyroid:
 Cancer:	

Other:

	

Allergies	
Please record any allergies or sensitivities below	

Vaccinations	

Have you received all routine vaccinations?                          Yes	 No

Did you receive all your routine vaccinations in the UK?       Yes	 No
	
Current Medication	
Please check and include as much information about your current medication below
Please give us your previous repeat medication list if possible and a medication review appointment may be needed

3. Your Lifestyle	
Alcohol	
Please answer the following questions which are validated as screening tools for alcohol use:	

AUDIT–C QUESTIONS	Scoring System	Your Score	
	0	1	2	3	4		
How often do you have a drink containing alcohol?	Never	Monthly or Less	2-4 times per month	2-3 times per week	4+ times per week		
How many units of alcohol do you drink on a typical day when you are drinking?	1-2	3-4	5-6	7-9	10+		
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 		

A score of less than 5 indicates lower risk drinking 	TOTAL:		
                                    Scores of 5 or more requires the following 7 questions to be completed:	
AUDIT QUESTIONS
(after completing 3 AUDIT-C questions above)	Scoring System	Your Score	
	0	1	2	3	4		
How often during the last year have you found that you were not able to stop drinking once you had started?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 		
How often during the last year have you failed to do what was normally expected from you because of your drinking?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 		
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 		
How often during the last year have you had a feeling of guilt or remorse after drinking?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 		
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 		
Have you or somebody else been injured as a result of your drinking?	No		Yes, but not in last year		Yes, during last year		
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?	No		Yes, but not in last year		Yes, during last year		
 	TOTAL:		

3. Your Lifestyle - Continued	

Smoking	
Do you smoke?	 Never smoked   	 Ex-smoker        	 Yes     	
Do you use an e-Cigarette?	 No                     	 Ex-User            	 Yes     	
How many cigarettes did/do you smoke a day?	 Less than one      	 1-9        10-19  	 20-39     40+	
Would you like help to quit smoking?	 Yes                   	 No		
	For further information, please see: www.nhs.uk/smokefree	

Height & Weight	
Height (metres)		
Weight (kg)		
Waist Circumference (cm)		

Women Only	
Do you use any contraception?
Do you have a coil or implant insitu	 Yes      No   If needed, please book appointment.
 Yes      No   Date inserted: 	
Are you currently pregnant or think you may be?	 Yes      No   Expected due date:	

Students Only	
Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth 	
I am less than 24 years old and have had two doses of the MMR Vaccination	 Yes   	 No        	 Unsure    	
I am less than 25 years old and have had a Meningitis C Vaccination	 Yes                   	 No            	 Unsure   	

4. Further Details	

Electronic Prescribing	
If you would like your prescriptions to be sent electronically, 
please provide details of the pharmacy you would like to use:	Pharmacy:	

** If you would like to receive our surgery newsletters please visit www.queensavenue.co.uk to sign up.

Blood and Organ Donation	
Blood Donation	 I am already a blood donor
 I wish to be a blood donor
 I do not wish to be a blood donor
To register please visit: www.blood.co.uk/the-donation-process/recognising-donors 
or call 0300 123 23 23	
Organ Donation	You will automatically be considered that you agree to become an organ donor when you die unless you are under 18, have opted out or are in an excluded group.

For further information, please see: www.organdonation.nhs.uk	

Signatures	
Signature	

I confirm that the information I have provided is true to the best of my knowledge.
 Signed on behalf of patient	
Name		
Date		

5. Online Access to Your Health Record	

We offer an online service which will enable you to order prescriptions, book appointments and have access to aspects of your medical record. We require photo ID (passport, driving licence) to enable access. Please ask a receptionist for details.	

6. Sharing Your Health Record	

Your Health Record	
Do you consent to your GP Practice sharing your health record with other organisations who care for you? (e.g. Emergency Departments)

     Yes   (recommended option)
     No, never

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

     Yes  (recommended option)
     No	

Your Summary Care Record (SCR)	

Do you consent to having an Enhanced Summary Care Record with Additional Information?

     Yes  (recommended option)
     No

Signature	
Signature		
	 Signed on behalf of patient	
Name		
Date		

7. Data Sharing for Research (not for direct care)	
Please note:

You can also tell your GP practice if you do not want your confidential patient information held in your GP medical record to be used for purposes other than your individual care. This is commonly called a Type 1 opt-out. This opt-out request can only be recorded by your GP surgery.

I do not wish identifiable data about me to leave the practice                                   (For practice use only - XaZ89)

Name: ______________________________________                         Signature: ____________________________

Date: __________________________

You can also object to any information containing data that identifies you from leaving the NHS Digital secure environment. This is the National Data Opt-out and can no longer be set by your GP. This includes information from all places where you receive NHS care, such as hospitals. If you object, confidential information will not leave NHS Digital and will not be used, except in very rare circumstances for example in the event of a public health emergency.

You can change your choice at any time.
To find out more or to make your choice visit: nhs.uk/your-nhs-data-matters or call 0300 303 5678	

Sharing Your Health Record

What is your health record?
Your health record contains all the clinical information about the care you receive.  When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?
Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

•	Sharing your contact details 	This will ensure you receive any medical appointments without delay
•	Sharing your medical history 	This will ensure emergency services accurately assess you if needed
•	Sharing your medication list	This will ensure that you receive the most appropriate medication
•	Sharing your allergies		This will prevent you being given something to which you are allergic 
•	Sharing your test results 	This will prevent further unnecessary tests being required

Is my health record secure?
Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?
Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?
Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?
If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?
If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?
Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?
Queens Avenue Surgery will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see: www.nhs.uk/NHSEngland/thenhs/records
For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters