Online Patient Registration Form Step 1 of 18 5% Have you recently moved to the UK from abroad?Please select…YesNoWhat date did you move to the UK? Day Month Year What is your country of origin? Do you have any communication needs?Please select…YesNoPlease state your needs below: Have you been registered with us before?Please select…YesNoName of previous surgery Surgery address Street Address Address Line 2 City Postcode Surgery contact number Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Date of birth Day Month Year NHS Number (if known) Optional Gender Female Male Other Please specify Marital statusPlease select…SingleMarriedSeparatedWidowedCo-Habiting Main language spoken Do you need an interpreter? Yes No Religion Optional Ethnicity British Irish Any Other White Background White & Black Caribbean White & Black African White & Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other Black background Chinese Any other ethnic group I do not want to give my ethnicity Patient services monitoring – strictly confidentialYour address Street Address Address Line 2 City Postcode Previous address Street Address Address Line 2 City Postcode Are you a nursing home resident? Yes No Are you a care home resident? Yes No Are you housebound? Yes No Your contact numberYour work telephone number OptionalYour mobile telephone number OptionalWould you like to receive text message appointment reminders from the surgery as well as other recalls? Yes No Your email address Enter Email Confirm Email Would you like to receive email messages from the surgery? Yes No Do you consent to the surgery leaving messages on your phone? I consent to the surgery leaving messages on my phone OptionalWe will not leave detailed messages on your phone, but may ask you to contact us or leave a simple message if we do not need to speak to you. Next of kinNext of kin's name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Are they registered at this surgery?Please select…YesNoNext of kin's date of birth Day Month Year Next of kin's address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Next of kin's contact numberRelationship to patient Please confirm below if the above next of kin's access is to be limited in anyway. OptionalI give permission for the practice to communicate with the person identified above in regard to my medical records I give my permission Do you have a carerPlease select…YesNoCarer's name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Carer's address Street Address Address Line 2 City Postcode Carer's contact numberRelationship to patient Is this the person we need to contact in case of an emergency?Please select…YesNoCan this person discuss your care record with us?Please select…YesNoAdditional information Optional Please detail below any specific needs you have so the practice can ensure they are identified and accommodated by taking the appropriate action: OptionalPlease state any sensory impairment you have. OptionalAre you an assistance dog user?Please select…YesNoPlease state any physical disabilities you have OptionalPlease state any mental disabilities you have OptionalPlease state any requirements you have to be able to access the practice premises OptionalPlease state any religious or cultural needs OptionalDo you have any allergies?Please select…YesNoPlease provide detailsDo you have any specific nutritional requirements?Please select…YesNoPlease provide detailsDo you have any phobias?Please select…YesNoPlease provide detailsDo you have a "Living Will"? (A statement explaining what medical treatment you would not want in the future)?Please select…YesNoPlease provide a copyMax. file size: 50 MB.Have you nominated someone to speak on your behalf (e.g. a person who has power of attorney)?Please select…YesNoPlease provide details Do you have any serious illnesses, or have had any serious accidents or operations?Please select…YesNoPlease provide details of any serious illnesses, accidents or operationsPlease provide the dates of when each of them occurred.Are you currently under the care of a hospital specialist?Please select…YesNoPlease provide detailsDo you have any major disability / handicapPlease select…YesNoPlease provide details Do you currently or have you ever suffered from Asthma?Please select…YesNoDate of first occurence Day Month Year Do you currently or have you ever suffered from Bronchitis?Please select…YesNoDate of first occurence Day Month Year Do you currently or have you ever suffered from Hay Fever?Please select…YesNoDate of first occurence Day Month Year Do you currently or have you ever suffered from Eczema?Please select…YesNoDate of first occurence Day Month Year Do you currently or have you ever suffered from Depression?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have you ever suffered from Cancer?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have you ever suffered from Glaucoma?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have you suffered from Epilepsy?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have you ever suffered from Diabetes?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have ever suffered from High Blood Pressure?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have you ever suffered from Heart Attack?Please select…YesNoDate of first occurrence Day Month Year Do you currently or have you ever suffered from Stroke?Please select…YesNoDate of first occurrence Day Month Year Is there any history of any of the previous conditions in your family?Please select…YesNo Have any close relatives ever suffered from any of the following? Heart Disease Stroke Diabetes Asthma Cancer None of the above Are you taking any medication?Please select…YesNoPlease provide details Electronic Prescribing Services (EPS)Please state your nominated pharmacy Optional If you do not already have a nominated pharmacy please select one from below OptionalPlease select…Boots (Castle Quay)Boots (Retail Park)KnightsSuperdrugMiddleton CheneyBloxhamPeak (Orchard Way)Well (Previously Frosts)Peak (South Bar House) Have you been immunised against Diphtheria, Tetanus, Pertussis (whooping cough), Polio, Hib, Hepatitis B ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against MenB ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Rotavirus / Gastroenteritis? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Diphtheria, Tetanus, Pertussis (whooping cough), Polio, Hib, Hepatitis B (2nd) ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Pneumococcal (13 serotypes) ? Yes No If yes, please provide the date you received the immunisation Day Month Year Have you been immunised against Rotavirus (2nd) ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Diphtheria, Tetanus, Pertussis (whooping cough), Polio, Hib, Hepatitis B (3rd) ? Yes Optional No Optional Please provide the date you received the immunisation Day Month Year Have you been immunised against MenB (2nd) ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Hib, MenC? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Pneumococcal (2nd) ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Measles, Mumps, Rubella ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against MenB (3rd) ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Diphtheria, Tetanus, Pertussis (whooping cough), Polio ? Yes No Please provide the date you received the immunisation Day Month Year Have you been immunised against Measles, Mumps, Rubella (2nd) ? Yes No Please provide the date you received the immunisation Day Month Year Please provide information of any other immunisations you have received Optional What is your height What is your weight? Do you smoke? Yes No I’m an ex-smoker How many do you smoke? When did you stop? Do you vape? Yes No Do you drink alcohol? Yes No What is your average intake per week in units? 1 unit = half pint of beer, lager or cider OR 1 measure of spirit OR 1 small glass of wine (75ml)How often do you have 6 or more drinks on one occasion ?0 – Never1 – Less than Monthly2 – Monthly3 – Weekly4 – Daily or almost dailyHow often do you have 8 or more drinks on one occasion ?0 – Never1 – Less than Monthly2 – Monthly3 – Weekly4 – Daily or almost dailyHow often do you have 8 (men) 6 (women) or more drinks on one occasion ?0 – Never1 – Less than Monthly2 – Monthly3 – Weekly4 – Daily or almost dailyHow often in the last year have you not been able to remember what happened when drinking the night before?0 – Never1 – Less than monthly2 – Monthly3 – Weekly4 – Daily or almost dailyHow often in the last year have you failed to do what was expected of you because of drinking?0 – Never1 – Less than monthly2 – Monthly3 – Weekly4 – Daily or almost dailyHas a friend / relative / doctor / health worker been concerned about your drinking or advised you to cut down?0 – Never1 – Less than monthly2 – Monthly3 – Weekly4 – Daily or almost dailyDo you have a history of substance addiction? Yes No Please provide details Do you keep to any particular diet? Yes No Please provide details Do you take any regular exercise ? Yes No Please provide details How many pregnancies have you had? Optional Did you have any associated difficulties? Yes Optional No Optional Please provide details Have you had a hysterectomy? Yes Optional No Optional Are you taking oral contraceptives Yes Optional No Optional Which brand and for how long? Are you on the Depo-Provera injection? Yes Optional No Optional When was the last one given? Have you got a coil (IUCD) in situ Yes Optional No Optional When was it inserted and what type is it ? Have you had a cervical smear test? Yes Optional No Optional When and where? What was the result ? Have you had a breast – screening test ? Yes Optional No Optional When and where ? As a practice, we fully support the armed forces covenant. We can only do this if we know our patients’ connections to the armed forces.Please tick the below boxes that apply to you. I am a military Veteran Optional I am currently serving in the Reserve Forces Optional I am married / civil relationship to a serving member of the Regular / Reserve Armed Forces Optional I am married / civil partnership to a Military Veteran Optional Do you have a DNA CPR form in placePlease select…YesNoDoes your family hold a lasting power of attorney for health and welfare for you ? OptionalPlease select…YesNoPlease provide the surgery with a copy so that this can be document on your medical notes. Drop files here or Select files Max. file size: 50 MB. Summary care recordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you want important information from your GP record to be available to other health and care professionals? Yes, share a Summary Care Record with additional information -Includes details of your medicines, allergies, adverse reactions, significant illnesses, health problems, operations and vaccinations Yes, share a Summary Care Record without additional information – Includes details of your medicines, allergies and adverse reactions only No, do not share a Summary Care Record Online record accessI wish to apply for online access to my medical records Yes No Email Enter Email Optional Confirm Email Optional I wish to have access to the following services Booking appointments Optional Requesting repeat prescriptions Optional Access my coded medical records, including laboratory results, immunisations, medications and consultations Optional I wish to have access to my medical record online and understand and agree with each following statement I have read and understood the information leaflet Optional I will be responsible for the security of the information that I see or download Optional If I choose to share my information with anyone else, this is at my own risk Optional If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible Optional If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible Optional If I think that I may come under pressure to give access to someone else unwillingly, I will contact the practice as soon as possible Optional Signature Proxy AccessI wish to apply for online proxy access to medical records Yes No I wish to have proxy access to the following services Booking appointments Optional Requesting repeat prescriptions Optional Access my coded medical records, including laboratory results, immunisations, medications and consultations Optional I wish to have access to the patient's medical record online and understand and agree with each following statement I have read and understood the information leaflet Optional I will be responsible for the security of the information that I see or download Optional If I choose to share my information with anyone else, this is at my own risk Optional If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible Optional If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible Optional If I think that I may come under pressure to give access to someone else unwillingly, I will contact the practice as soon as possible Optional Signature of proxyName of proxy First Optional Last Optional Email of proxy Enter email Optional Confirm email Optional Proxy's date of birth Month Optional Day Optional Year Optional Relationship to patient Optional Signature of patient OptionalName of patient First Optional Last Optional Patient's date of birth Month Optional Day Optional Year Optional
