Additional details about you What is your ethnic group? Name of next of kin \ Emergency contact
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1 Thank you for applying to join The Hedges Medical Centre. We would like to gather some information about you and ask that you fill in the following questionnaire. You don t have to supply answers to all of the questions but what you do fill in will help us give you the best possible care. Please supply two forms of Identification with your completed form, a photographic form of ID (such as passport or driving license) and proof of your home address (such as a recent bank statement or document relating to your new home). Please complete all areas in CAPITAL LETTERS and tick the appropriate boxes. Fields marked with an asterix (*) are mandatory. *Title *First names *Any previous surname(s) The Hedges Medical Centre, Pasley Road, Leicester, LE2 9BU Telephone *Surname *Date of Birth * Male Female Intermediate Unspecified *NHS No. Town and country of birth *Home address & Postcode Home telephone No. Work telephone No. Preferred Number Yes No Preferred Number Yes No *Previous address & Postcode Mobile No. Preferred Number Yes No address If you are from abroad please tell us your first UK address where registered with a GP: Previous GP Details: If previously resident in UK, date of leaving: Date you first came to live in UK: (for women only) Have you had a cervical smear? Yes No (Please state where, when and the result if possible) Marital Status? Single Married Divorced Widowed Additional details about you What is your ethnic group? *Main spoken languages White Black British Caribbean Irish African English Asian Mixed Other Indian White + Black Caribbean Please specify: Pakistani White + African Chinese White + Asian Interpreter required? Yes No Have you ever been in the employ of the Armed Forces? Yes No Personnel Number: Date Enlisted: Date Left: Are you a dependant of a current serving member of British Armed Forces? Yes No Next of kin \ Emergency contact Name of next of kin \ Emergency contact Relationship to you Next of kin \ Emergency contact telephone number(s) Next of kin \ Emergency contact address (if different to above)
2 Data Sharing Summary Care Record (SCR) Your SCR is an electronic summary of key medical information taken from your GP medical record. If you need healthcare away from your usual doctor s surgery, your enhanced SCR will provide those looking after you with key information to help them give you better and quicker care. Please refer to What is a Summary Care Record document for more information or visit: Tick this box if you wish to have an enhanced SCR with core and additional information (recommended) Tick this box if you wish to opt-out of the SCR Medical Interoperability Gateway (MIG) The MIG enables secure sharing of relevant medical information from your GP record with other healthcare professionals who are providing you with direct care, even if they are not using the same electronic records system. At point of care you will be asked if you consent to the care service seeing essential elements of your record. More information can be found by visiting: Tick this box if you wish to opt-out of the MIG data sharing Risk Stratification Preferences Risk stratification is the process of identifying the relative risk of patients in a population by analysing their medical history. It's a key enabler for improving the quality of care delivered by the NHS. The Hedges Medical Centre is taking part in the Risk Stratification programme and will be uploading patient identifiable data for analysis. Patient identifiable information will only be viewable at GP practice level. Any NHS organisation external to the practice using risk stratification will only see anonymised data. For more information please visit our website at Tick this box if you wish to opt-out of the Risk Stratification programme Enhanced Data Sharing Module (EDSM) The Hedges Medical Centre uses a clinical computer system called SystmOne to record your medical information. With your consent, you can allow your full GP record to be shared with other healthcare services that are providing care for you and who also use SystmOne. These other services will always ask consent to view your record. For more information please visit our website at Tick this box if you wish to opt-out of the Enhanced Data Sharing Module *Do you consent to receive the following types of communication (if offered) from The Hedges Medical Centre? Yes No Mobile phone text messages Yes No Answering machine messages Yes No Safeguarding Information If you are applying on behalf of a child who is in foster care/residential care/kinship care/ or who is not your child Who has the legal responsibility for the child? Who can consent for the medical treatment for the child? You as the legal parent or guardian You as the legal parent or guardian Looked after Children Are you looking after someone else s child? Yes No If Yes, under what arrangements: Section 20-Voluntary Care Interim Care Order Care Order Child arrangement order/residence Order Special Guardianship order Placed for adoption Private arrangement/private Fostering/informal arrangement (please note you have a duty to notify social care of this arrangement)
3 Medical details In order to continue to receive your repeat medications you ll need to make an appointment to see one of the GPs and bring in your last repeat prescription. Please allow plenty of time to organise repeats. Please provide us with your repeat medication list found on the right hand side or a printed prescription. *Are you allergic to any medicines? Yes No (if yes please specify) *List other allergies / intolerances (i.e. nuts, gluten, pollen, animal hair or certain foods. Please mark none if you have no other allergies that you know of) Have you ever had any of the following conditions? Epilepsy Yes Year Mental Illness Yes Year High Blood Pressure Yes Year Diabetes Yes Year Heart Attack / Angina Yes Year Asthma Yes Year Stroke / Mini-stroke (TIA) Yes Year COPD (or Emphysema) Yes Year Cancer Yes Year Osteoporosis / Bone fractures Yes Year Rheumatoid Arthritis Yes Year Peripheral vascular disease Yes Year Do you have any disabilities, illnesses or accessibility needs? I.e. needing to be seen in ground floor consulting rooms or use of a specific communication device such as a hearing aid? If yes, please tell us how we can support your needs. The Accessible Information Standard (AIS) Please use this space to tell us about any specific communication needs you have. I.e. needing information in large print or deafblind telephone contact. For further information please visit Do you have family history of any of the following? High Blood Pressure Yes Who DVT / Pulmonary Embolism Yes Who Ischaemic Heart Disease Yes Who Breast Cancer Yes Who Diagnosed aged >60 yrs Ischaemic Heart Disease Yes Who Any Cancer Yes Who Diagnosed aged <60 yrs Specify type: Raised Cholesterol Yes Who Thyroid disorder Yes Who Stroke / CVA Yes Who Epilepsy Yes Who Asthma Yes Who Osteoporosis Yes Who Please tell us about your smoking habits Do you smoke? Yes No If Yes, what do you primarily smoke: Cigarettes / Cigar / Pipe (please circle) How many do you smoke a day? Would you like advice on quitting? Yes No Are you an ex-smoker Yes No When did you quit? How many did you used to smoke a day?
4 Please tell us about your alcohol consumption Questions (please circle your answers) 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? Unit scoring system Never Monthly or less 2-4 times Per month 2-4 times per week 4+ times per week 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 Depending on your answers above you may be asked to complete an additional alcohol questionnaire. Daily or almost daily Do you exercise regularly? Yes No If so What exercise do you take? How often? *In accordance with the Data Protection Act, the practice needs consent if you are happy for a 3 rd party to collect prescriptions, test results and other medical information on your behalf. Please complete this section if you would like to register a 3 rd party. I give consent for to collect prescriptions on my behalf (Please note that we are unable to hand out prescriptions to anyone under the age of 15) I give consent for to obtain test results / medical information / appointment information on my behalf (Delete as appropriate) IT IS YOUR RESPONSIBILITY TO ADVISE US OF ANY CHANGES TO THESE INSTRUCTIONS: Signed: Date: Please record any additional information about you that you think is important for us to know
5 Electronic Prescription Service (EPS) EPS enables prescribers - such as GPs and practice nurses - to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. If you have already nominated a pharmacy, please tell us which pharmacy you have chosen. For further information about this service, please talk to your pharmacist of choice. Patient Participation Group (PPG) The Hedges Medical Centre has a lively and committed Patient Participation Group which meets monthly and new members are always welcome. Please contact Jessica Parsons, Practice Manager, for more information or if you are interested in joining. Carers Information A carer is a friend or family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided. A carer can receive Carers Allowance, but not a wage and the care they are giving will significantly affect their own life. Are you looked after by someone whose support you could not manage without? Yes No If yes, what is their name and contact number? Do you consent for your carer to be informed about your medical care? Yes No Do you look after or support someone who couldn t manage without you? Yes No If yes, do you look after someone who is a patient of The Hedges Medical Centre? Yes No Don t know If yes, what is their name? Are they a: Relative Friend Neighbour *Signed *Date / / / Signed on behalf of patient (if applicable) (e.g. for minors under 16 years old, adults lacking capacity) Once you are registered If there are any problems with your registration we ll contact you to clarify any issues, but once your details have been entered into our computerised records On-line Services You will be able to register with our on-line service and access appointments, prescriptions and some sections of your own medical record via the internet. All of the details that you need for this are available by requesting to be registered at reception. FOR OFFICE USE ONLY PHOTO ID (Over 18 only) ADDRESS ID TYPE: TYPE:
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