PATIENT QUESTIONNAIRE (ADULTS) - Redgate Medical Centre
Adults 16yrs +
(Reviewed June 2013)
REDGATE MEDICAL CENTRE
Westonzoyland Road
Bridgwater
Somerset
TA6 5BF
Tel: 01278 454560
Fax: 01278 446816
redgatemedicalcentre.co.uk
May we take this opportunity to welcome you to Redgate Medical Centre and ask that you carefully read and complete the attached questionnaires listed below:
1. New Patient Health Questionnaire (Please complete all fields)
2. Medication Request (Only complete if you are currently
taking medication)
3. Summary Care Record (Only complete if you wish to opt out
of having a Summary Care Record)
ONCE COMPLETED, PLEASE HAND THE COMPLETED FORMS TO THE RECEPTIONIST
WITH A FORM OF IDENTIFICATION OR CONFIRMATION OF YOUR CURRENT ADDRESS
We will not be able to process your registration without any of the above
Thank you for your co-operation
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TO BE COMPLETED BY THE RECEPTIONIST
New Patient Health Check Arranged ………………………………………………
Practice Booklet Given ………………………………………………
Receptionist Signature ………………………………………………
Date Forms Completed ………………………………………………
Date Patient Registered ………………………………………………
Dr D M Hynes MB BCh MSc MRCP(UK) DGM * Dr S J Akhter FRC
Also
Somerset Bridge Medical Centre Taunton Road, Bridgwater, Somerset TA6 6LD
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NEW PATIENT HEALTH QUESTIONNAIRE (ADULTS) – 16yrs and over
Please complete this form as fully as possible, as we are unable to complete your registration without this information
HAVE YOU PREVIOUSLY BEEN REGISTERED WITH THE SURGERY Yes No
Registration and Family Details
Surname …………………………………….......…………… Forenames ………………………………………..............……………...
NHS No: ………………………………………………………. Previous Surname(s) (if any) ……………………………………….…...
Title (Mr., Mrs., Miss etc.) ………………….......…………… Occupation ………………………………………………………………...
Date of Birth ……………………………………...............…. Place of Birth ………………………………………………….…………..
Next of Kin (Name, Relationship & Contact Details) ……………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
CURRENT Address …………………………………………………………………………………………………………………………………
………………………………………………………………………………………….. Postcode ………………………………………………..
PREVIOUS ADDRESS ……………………………………………………………………………………………………………………………..
PREVIOUS GP …………………………………………………………………………………………………………………………………….
Home Telephone Number ………………………………… Mobile Tel Number or Other ………………………..…………………………
What is your First Language? …………………………………………………………………………………………………………………….
Ethnic Groups (please tick one option and delete as appropriate)
White – British/Irish/Other – please specify ……………………………………………………………………………………………
Black – Caribbean/African/Other – please specify ………………………………………………………….………………………..
Asian – Indian/Pakistani/Chinese/Other – please specify …………………………………………….……………………………..
Mixed – White & Black Caribbean/White & Black African/White & Asian/Other mixed – please specify …………………….…
I DO NOT WISH TO GIVE THIS INFORMATION
NHS CARE RECORDS SERVICE (please read the attached Summary Care Record form)
Your Summary Care Record will be securely uploaded to the National Spine on signing this registration form so that wherever in the country you need care, healthcare professionals can have access to the most up-to-date information. IF YOU DO NOT WANT A SUMMARY CARE RECORD, YOU WILL NEED TO ‘OPT-OUT’ by Signing the attached Summary Care Records form.
Proof of Identity Birth Certificate Driving Licence Passport Utility Bill Other
Medical Information
Please list any serious illnesses/operations/accidents/disabilities (and for women any pregnancy related problems) and the year they took place:
………………………………………….. ……….….………..……... ………….……………………..…….. …………………………...
………………………………………..… ………….……………..…. ………………………..……………… …………………………..
Are you a military veteran Yes/No If yes, Force served Army Royal Navy RAF
Do you have a carer? Yes/No IF ‘YES’ PLEASE COMPLETE A CARERS IDENTIFICATION AND REFERRAL FORM
Are you a carer? Yes/No IF ‘YES’ PLEASE COMPLETE A CARERS IDENTIFICATION AND REFERRAL FORM
Are you registered disabled? Yes/No If yes, please give details of your disability ………………………………………………….
Do you have any known allergies, if so which? ……………………………………………………………………………………………..….
Do you currently smoke? Yes/No If ‘Yes’ how many cigarettes a day …………………………………………………………..
If no, have you ever smoked? Yes/No ounces of tobacco a week …………………Quit Date …… ………..……......…………….
Please let us know is you would like smoking cessation advice Yes No
Your Height …….…………………………….. Your Weight …………….……………………
Family History
Please state any serious illness, in particular heart disease, strokes, high blood pressure diabetes or any inherited disease:
…………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
For Patients aged 65 and over or those with a Chronic Disease (e.g. asthma, diabetes etc.)
Have you had a ’flu vaccination? Please enter year …….. ………………………………………………………………………………...
Have you had a pneumococcal vaccination? Please enter year …………. …………………………………………………………………
’flu vaccination by ticking here
Please indicate if you do not wish to have a
a pneumococcal vaccination by ticking here
Are you rubella immune (German measles) Yes/No
Do you want contraceptive care? Yes/No
Are you taking the oral contraceptive? Yes/No
Are you fitted with a coil? Yes/No If Yes, when was your last coil check? ………………………………………………………….………….
Have you had a cervical smear? Please enter year or ‘never’ ………………………………………….......................……………………….
Have you had a hysterectomy? Yes/No
Please note that unless you have had a hysterectomy it is strongly advised that you have regular smears. You will automatically receive reminders at the currently recommended interval..
Preferred Pharmacy
LLOYDS: Redgate Taunton Road Somerset Bridge North Petherton Victoria Park
Superdrug Sainsburys Boots Quayside Asda Cranleigh Gardens Rowlands
If you are currently taking medication, please list below then complete page 4 with your previous practice details::
……………………………………..…… ………….………..………. …………………..…………………… …………………………..
……………………………………..…… ………….…………..……. ………………………..……………… …………………………..
Please complete this page if you are currently taking medication
Patients Full Name:
Patients Date of Birth:
Patients Previous Address:
Date of last prescription (if known):
Name & Address of Previous Surgery:
ALCOHOL CONSUMPTION
This is one unit of alcohol…
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…and each of these is more than one unit
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AUDIT – C
|Questions |Scoring system |Your score |
| |0 |1 |
|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 the last year | |Yes, during the 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 the last year | |Yes, during the last year | | |
Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence
TOTAL Score equals
AUDIT C Score (above) +
Score of remaining questions
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YOUR NAME: DATE OF BIRTH:
Redgate Medical Centre offers its patients the choice of having a Summary Care Record.
The new NHS Summary Care Record has been introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with.
What is the NHS Summary Care Record?
The Summary Care Record contains basic information about:
• Any allergies you may have
• Unexpected reactions to medications
• And any prescriptions you have recently received
The intention is to help clinicians in Accident and Emergency Departments and ‘Out of Hours’ health services to give you safe, timely and effective treatment.
Clinicians will only be allowed to access your record if they are authorised to do so and, even then, only if you give your express permission. You will be asked if healthcare staff can look at your Summary Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. You can refuse if you think access is unnecessary.
Children under the age of 16
Patients under 16 years will not receive this form, but will have a Summary Care Record created for them unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please either make this information available to them or decide and act on their behalf. Ask the surgery for additional forms if you want to opt them out.
You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you are happy for a Summary Care Record to be set up for you then you need take no further action. If you want to opt-out now please tick the box below and return it to Reception within the next three days.
Please tick the box and sign below:
No I do not want a Summary Care Record Yes I want a Summary Care Record
Signed____________________________ Date__________________________
HealthSpace information
In addition, patients over 16 can register on a secure website called HealthSpace for a ‘Basic’ account which gives you access to a Personal Health Organiser. Register at healthspace.nhs.uk to do this. If you go a stage further you can register for an ‘Advanced’ account which will entitle you to see a copy of your Summary Care Record once it has been created. Complete the Advanced Registration application and print off the form and contact your Patients’ Advice and Liaison Service (PALS) office to find out where you should go to register for an Advanced HealthSpace Account. You can do this by emailing healthspace@somerset.nhs.uk or by telephoning the PALS on 0800 0851 067. Advisers are available Monday to Friday from 9.00am to 5.00pm. When you register you must remember to bring along with you 3 items of identification, Passport and/or Driving Licence and 2 Utility Bills current within the last 3 months.
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