Online Registration Form & Medical Questionnaire

Non-urgent advice: Important

This form is for patients wishing to register with the Alton Street Street Surgery, Ross-on-Wye, HR9 5AB ONLY.

New Patient Registration Form (GSM1 + Health Q’s)

If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form.

Step 1 of 2

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This form is for patients wishing to register with the Alton Street Street Surgery, Ross-on-Wye, HR9 5AB ONLY.

I understand I am registering with Alton Street Surgery, Ross-on-Wye, HR9 5AB.

Personal Details

Title

Mrs

Miss

Other

NHS Number Optional

First Names

Surname

Previous Surname Optional

Date of Birth

Day

Month

Year

Gender

Female

Male

Ethnicity

First Spoken Language

Town and Country of Birth

Address

Street Address Address Line 2 City Postcode

Main Contact Number

Home Contact Number Optional

Enter Email Optional Confirm Email Optional

Please help us trace your previous medical records by providing the following information:

Your previous address in the UK

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Name of doctor while at that address Optional

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional

If you are from abroad

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

Day Optional

Month Optional

Year Optional

Supplementary Questions

Are you ordinarily a resident in the UK?

Yes

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes Optional

No Optional

Demographics

Marital Status

Single, never married

Married

Civil Partnership

Divorced

Widowed

Separated

Which of the following options best describes you?

Heterosexual or Straight

Gay or Lesbian

Bisexual

Prefer not to say

In another way

Sex and gender identity – Which one of the following best describes how you think of yourself?

Male (including trans men)

Female (including trans women)

Non-binary

Prefer not to say

In another way

Is your gender identity the same as the gender you were given at birth?

Yes

Prefer not to say

Please specify the ethnic group you consider you belong to

English

Welsh

Scottish

Northern Irish

British

Irish

Gypsy or Irish

Traveller

Any other White background

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed / Multiple ethnic background

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

African

Caribbean

Any other Black / African / Caribbean background

Arab

Any other ethnic group

Prefer not to say

What is your main religion?

No religion Optional

Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional

Buddhist Optional

Hindu Optional

Jewish Optional

Muslim Optional

Sikh Optional

Other religion Optional

Communication Needs

Do you speak English?

Yes

Do you read English?

Yes

Are you a British Sign Language user?

Yes

What is your main spoken language?

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

No known impairment, health condition or learning difference Optional

A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional

A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional

A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional

A learning difficulty Optional

Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional

Deaf or hearing impaired Optional

Blind or have a visual impairment uncorrected by glasses Optional

An impairment, health condition or learning difference that is not listed above Optional

Prefer not to say Optional

Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) Optional

Armed Forces

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?

Yes

Do you have access to secure housing?

Yes

What is your current immigration status?

Asylum Seeker Optional

Failed Asylum Seeker Optional

Carers

Do you have caring responsibilities?

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Do you have a carer?

Yes

Emergency Contact

Full Name

Relationship to you

Contact Number

Are they your next of kin?

Yes

Do you give us permission to discuss your medical records with them?

Yes

About You

Height

Weight

Smoking Status

Current Smoker

Ex Smoker

Never Smoked

What do you smoke?

e.g. Cigarettes, Vape, Cigars

How many do you smoke per day?

Are you interested in advice on how to quit?

Yes

Please state how much exercise and what type of exercise you do per week Optional

Alcohol Consumption

This is one unit of alcohol:

Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
1 small glass of sherry

Each of these is more than one unit:

Pint of regular Beer/Lager/Cider (2 Units)
Pint of Premium Beer/Lager/Cider (3 Units)
Alcopop or can/bottle of regular Lager (1.5 Units)
Can of Premium Lager/Strong Beer (2 Units)
Can of super strength lager (4 Units)
Glass of wine (2 Units)
Bottle of wine (9 Units)

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

Do you have any significant family history we should be aware of? Optional

Medical History

Major Illnesses Optional

Please include dates

Past Operations Optional

Please include dates

Family History Illnesses Optional

Please include dates

Current Medication Optional

We routinely offer HIV screening would you be interested in being screened?

Yes

Sight

Good

Poor

Registered Blind

Hearing

Good

Poor

Partially Deaf

Deaf

Are you over 75 years old?

The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care.

Please ask the name of the GP assigned to oversee your care.

Please note this does not prevent you from seeing the GP of your choice.

Allergies

Do you have any allergies?

Yes

Please specify what you are allergic to, what happens and when you had your first reaction

Immunisation History

Please list any immunisations/vaccinations you have had Optional

Please include dates

Important Registration Information

For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service

Summary Care Record

This 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 consent to having a Summary Care Record?

Yes

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Signature

Declaration

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional

Signature

Your Full Name

Date

Day

Month

Year