Welcome to Sacriston Surgery

Thank you for registering with the Practice.  We are delighted you have chosen this surgery to care for you.
New Patient Questionnaire
To help us provide the best possible level of care we can for you, we’d like to know more about you.

Please complete the questions below.
About you

Surname		Any previous surname(s)?
		First name(s)		
I like to be called	
	Date of birth		Age		
Address 	

	How long have you lived there?
     Years             Months	
Telephone Numbers
(and please tick which one you would prefer use to use)	Email address		
Landline			Are you?	Male  Female   Prefer not to so say 	
Mobile 			NHS Number		
What is your main spoken language?		If your main spoken language is not English, do you need an interpreter?                    Yes  No 	
Do you currently serve as a member of HM Armed Forces? 	Yes 

No  	Have you ever served as a member of HM Armed Forces? 	Yes 

No  	If you have answered ‘yes’ to either question, do you live with issues to do with 
Alcohol abuse                      Yes  No 
Drug / substance abuse     Yes  No 
Mental health                      Yes  No 
MSK problem*                     Yes  No 
(*that is, musculoskeletal conditions – problems with muscles, bones and joints)	
“A carer looks after a family member, friend, partner or neighbour who needs support due to illness, disability or old age. The help carers give is unpaid, though you may still receive Carer’s Allowance or other benefits. You do not have to care full time, receive Carer’s Allowance or live with the person you care for to be a carer.”

Reading this:
•	Do you think you are a carer?      Yes  No 
•	Do you think you have a carer?   Yes  No  if yes, who do you think is your carer? 
	
What is your ethnic group? Please tick one box
White								Mixed / Multiple ethnic groups
English / Welsh / Scottish / Northern Irish / British		White and Black Caribbean			      
Irish								White and Black African				      
Gypsy or Irish Traveller						White and Asian				      
Any other White background					Any other Mixed / Multiple ethnic background	      
Asian / Asian British						Black / African / Caribbean / Black British
Indian								African						      
Pakistani							Caribbean					      
Bangladeshi							Any other Black / African / Caribbean background    
Chinese								Other ethnic group
Any other Asian background					Arab					                    
								Prefer not to disclose my ethnic group		     
								Any other ethnic group				     
Are you employed? Yes  No Retired 	If you work, do you work part-time  full-time  Night shift 	
If you work, what do you do?	

Who is your next of kin?

Name		
Address
		
Telephone Number		
Email address
		
What is their relationship to you?	
	
Are you:	 Single  Married    Co-habiting  Separated  Divorced  Widow(er)
	
Have you any children aged below 16 years of age living with you? 
Yes     No  
	If you answered ‘yes’, please list their names, date of birth and age below
 	
		Full Name	Date of birth	Age now	
	Child 1				
	Child 2				
	Child 3				
	Child 4				

Who was your last GP?

Name of GP		
Name of Surgery 
		
Address of Surgery	

How long were you a patient there? 	                                 Years         Months	
Did you opt out of the Summary Care Record* at your previous surgery? Yes     No  

Do you wish to remain opted out?                                                                       Yes    No   

Please sign and date if you said ‘yes’ to the second question

Signature                                                                                    Date 

*The Summary Care Record (SCR) is an electronic record of important patient information created from GP medical records. Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. the SCR holds important information about:
•	current medication
•	allergies and details of any previous bad reactions to medicines
•	the name, address, date of birth and NHS number of the patient
The patient can also choose to include additional information in the SCR, such as details of long-term conditions, significant medical history, or specific communications needs.

Medical and Family History

Have you any illnesses at the moment? 
Yes    No  
If you answered ‘yes’ to this question, please list what your illnesses are			

			
			
Are you taking any medication at this time? 
Yes    No  
If you answered ‘yes’ to this question, please list what your medication are			

			
			
Have you any allergies? 	To medicines? 

Please list			

	Non-medicine related allergies? 
Please list			

Are you housebound?     Yes    No  

Have you or other family members suffered from the following:  Please tick

	You	Other family member	Relationship to you	Their age at diagnosis	
Heart problems	Yes    No  	Yes    No  			
Stroke	Yes    No  	Yes    No  			
High blood pressure	Yes    No  	Yes    No  			
Diabetes	Yes    No  	Yes    No  			
Glaucoma	Yes    No  	Yes    No  			
Cancer	Yes    No  	Yes    No  			
Epilepsy	Yes    No  	Yes    No  			
Asthma	Yes    No  	Yes    No  			

If either/both parents are dead, state age and cause

	Age they died	Cause of death	
Father			
Mother			

About your lifestyle 

Do you smoke? 	Yes    No  	If yes, how many do you smoke per day? 	 Cigarettes
 Cigars
 Pipes
 Vaping	
If you are an ex-smoker, how long did you smoke for?
	    Years             Months	
Are you exposed to smoke	At work?	Yes    No  	 At home?   	Yes    No  	
Your current height	 feet     inches 	Or	 metre  centimetres
	
Your current weight	 stone  pounds		 kilos     grams
	
Do you drink alcohol? 	Yes    No  	If ‘yes’, how many units per week? 
	
How many minutes exercise do you do per week? 	 minutes	

To help you answer the last two questions, here’s some information: 

“What is a unit of alcohol?” I hear you ask…….

How much exercise should I be doing? 

Women Only

Are you using contraception?	Yes    No  	If ‘yes’, what method of contraception are you using? 	
Do you know about long acting reversible contraception (LARC)?	Yes    No  	If ‘no’, would you like to discuss with a nurse?    	Yes    No  	
Have you had a hysterectomy?	Yes    No  	When was your last cervical smear?  		
When was your last mammogram?  		Can you remember the result of this last cervical smear? 		
Can you remember the result of your last mammogram?  		How many pregnancies have you had? 		

Thank you for completing this form.  All information is strictly private and confidential.  Is there anything else you feel your Doctor should know?

Name

Signed 

Date

Important Notes

•	Please note that you will be unable to see a GP until your registration is complete.  
•	If you are going to require repeat medication immediately after registration without seeing a doctor, please obtain full details from your previous GP and pass it to the receptionist with your written repeat prescription request.  We will be unable to issue repeat prescriptions without an appointment with a doctor if this information is not provided.

Important Notice about Organ Donation 

Whilst there is a section to join the NHS Donor Register on the GMSI form, it is now your responsibility to register your details on the register.

Should you wish to register/de-register your details on this register, you should go to www.organdonation.nhs.uk and do so on-line, or telephone 03001 232323 as this will NOT be carried out by the surgery.

Text Messages

We can now send you appointment confirmation messages and reminders by text message.  If you wish to receive these text messages we require your consent. Doctors can now also send text messages direct to patients; for example, a doctor may review a blood test and text a patient to arrange a follow up blood test in 3 months. 

If you wish to receive these text messages, please read the disclaimer below then complete and sign the slip below.  Return it to the surgery.  

a)	I consent to Sacriston Surgery contacting me by text message for the purposes of health promotion, results (in the future) and for appointment reminders.
b)	I acknowledge that appointment reminders by text are an additional service and that these may not take place on all occasions, and that the responsibility of attending appointments or cancelling them still rests with me.  I can cancel the text message facility at any time.

Text messages are generated using a secure facility.  I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure.  However, the practice will not transmit any information which would enable an individual to be identified.

I agree to advise the practice if my mobile number changes or if this is no longer in my possession.

Name

Signed 

Mobile number 

Date of birth

Date

For office use only:  Date received		       Date actioned		     Initials

Email

We can also send letters via email.  These will include letters inviting patients to clinics and appointments at the surgery, patient newsletters and other similar letters.

We require your consent to contact you via email.  If you wish to receive letters via email in the future, please complete and sign the slip at the bottom of the page and return it to the surgery.

I consent to Sacriston Surgery sending me letters via email.

Emails are sent through the NHS email service. I understand that they are sent via a public network to a personal email address and as such may not be secure.

I agree to advise the practice if my email address changes.

Name

Signed 

Email address

Date of birth

Date

For office use only:  Date received		       Date actioned		     Initials

Communication Consent

Would you like to be included in the following services?
•	SMS text messages
•	Email messages

We have the facility to use the above services to contact you.  These may be used to notify you of, for example:

•	Appointment reminders or changes to your booked appointment
•	National issues such as flu pandemics
•	The practice being closed due to unforeseen circumstances
•	Cancelled clinics including GP, nurse and health care assistant
•	Other notifications the practice deem necessary to your health care provision.

If you are happy for the GP Practice to contact you by these means, please complete the form enclosed and provide your contact telephone numbers and email address, including the area code for your landline number.

Disclaimer

•	The mobile phone number and email address will only be used by the GP Practice and will not be passed to any other parties.
•	If at any time you would like to opt out of the above services, please make a personal request to the GP Practice and you will be opted out of the service within 48 hours.  You may also like to include your reason for opting out, to help us review and improve this service in future.
•	Your mobile phone number and email address will solely be used by the GP Practice in relation to the health care services offered by the practice.  You will be contacted in relation to any other types of products or services.
•	No personal details will be included in the message to identify you.
•	Whilst the GP Practice will regularly check your contact details with you, please be aware that the onus of keeping your contact details current with the practice rests with you.

Patient Access Online Services

PLEASE speak to one of the Receptionist for more information about how to arrange on line access 

Book your next appointment
You can view, book and cancel appointments at your convenience.

•	Quick and easy to use
•	Avoid busy telephone lines
•	Access out of practice hours
•	Electronic management of your appointment

Request repeat prescriptions

•	Access a list of your repeat medication and request a repeat prescription.
•	Minimise your trips to the practice
•	Your request is authorised online by the practice, so you know when it is ready to collect
•	Avoid queues and busy telephone lines

Patient.co.uk
 Patient Access contains links to www.Patient.co.uk, a trusted comprehensive source of GP-authored   health information leaflets for patients.

 How to register
 To register, ask at reception for details

 Mobile app
 The free Patient Access app provides greater convenience for patients who are away from a computer, with access to a Smartphone. Download at patient.co.uk/accessapp

Safe and secure
 All data contained within Patient Access is protected using the highest standard internet security so you can be sure all your personal information is safe and secure.

e-consult 
 A virtual means of engaging with a GP: for fit note requests. See practice website for more information: www.sacristonsurgery.co.uk

A different way to get your medicines and appliances

The Electronic Prescription Service (EPS) is an NHS service. It gives you the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from. 

What does this mean for you? 
•	If you collect your repeat prescriptions from your GP you will not have to visit your GP practice to pick up your paper prescription. Instead, your GP will send it electronically to the place you choose, saving you time. 
•	You will have more choice about where to get your medicines from because they can be collected from a pharmacy near to where you live, work or shop. 
•	You may not have to wait as long at the pharmacy as there will be time for your repeat prescriptions to be ready before you arrive. 

Is this service right for you? 
Yes, if you have a stable condition and you: 
•	don’t want to go to your GP practice every time to collect your repeat prescription. 
•	collect your medicines from the same place most of the time. 
•	use a prescription collection service now. 

No, if you: 
•	don’t get prescriptions very often. 
•	pick up your medicines from different places. 
•	travel or work away from home a lot. 

How can you use EPS? 
You need to choose a place for your GP practice to electronically send your prescription to. This is called nomination. You can choose: 
•	a pharmacy. 
•	a dispensing appliance contractor (if you use one). 
•	your dispensing GP practice (if you are eligible). 

Ask any pharmacy or dispensing appliance contractor that offers EPS or your GP practice to add your nomination for you. You don’t need a computer to do this. 

Can I change my nomination or cancel it and get a paper prescription? 
Yes you can. If you don’t want your prescription to be sent electronically tell your GP. If you want to change or cancel your nomination speak to any pharmacist or dispensing appliance contractor that offers EPS, or your GP practice. Tell them before your next prescription is due or your prescription may be sent to the wrong place. 

Is EPS reliable, secure and confidential? 
Yes. Your electronic prescription will be seen by the same people in GP practices, pharmacies and NHS prescription payment and fraud agencies that see your paper prescription now. 

Sometimes dispensers may see that you have nominated another dispenser. For example, if you forget who you have nominated and ask them to check or, if you have nominated more than one dispenser. 

For more information about EPS visit www.cfh.nhs.uk/eps, or ask to speak to a member of the prescribing administration team from the surgery. 

Please complete following so we can set up your nominated pharmacy …

Name:						DOB:

I confirm I would like my medications to go to the following nominated dispenser:

Name of pharmacy:

Location of Pharmacy:

I am aware that if I wish to change my nominated pharmacy I must inform my GP surgery.

Signed:

Date: