NORTHFIELD MEDICAL CENTRE VILLERS COURT, BLABY, LE8 4NS Tel: , Web:

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1 NORTHFIELD MEDICAL CENTRE VILLERS COURT, BLABY, LE8 4NS Tel: , Web: Thank you f applying to join Nthfield Medical Centre. We would like you to 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 note you will need to also supply two fms of Identification with your completed fm, a photographic fm of ID (such as passpt driving license) and proof of your home address (such as a recent bank statement document relating to your new home). New Patient Questionnaire f patients aged Over 16 ** Please ensure you complete the attached Alcohol Questionnaire** Please complete all areas in CAPITAL LETTERS and tick the appropriate boxes. Fields marked with an asterix (*) are mandaty. *Title *Surname *First names *Any previous surname(s) *Date of Birth * Male Female Intermediate Unspecified *NHS No. Town and country of birth Home telephone No. Preferred Number Yes No *Home address & Postcode *Previous address & Postcode Wk telephone No. Preferred Number Yes No Mobile No. Preferred Number Yes No Please tick this box if you DO NOT wish to receive SMS text message reminders: *Previous GP Details address If you are from abroad please tell us your first UK address where registered with a GP: If previously resident in UK, date of leaving: Date you first came to live in UK: Marital Status? Single Married Divced Widowed Additional details about you What is your ethnic group? White British Irish Main Language Spoken? (E.g. English) Black Caribbean African Asian Indian Pakistani Chinese Mixed White + Black Caribbean White + African White + Asian Other Please specify: Have you ever been in the employ of the Armed Fces? Yes No Personnel Number: Date Enlisted: Date Left: Are you a dependant of a current serving member of British Armed Fces? Yes No

2 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) Data Sharing Summary Care Recd (SCR) Your SCR is an electronic summary of key medical infmation taken from your GP medical recd. If you need healthcare away from your usual doct s surgery, your enhanced SCR will provide those looking after you with key infmation to help them give you better and quicker care. Please refer to What is a Summary Care Recd document f me infmation visit: Tick this box if you wish to have an enhanced SCR with ce and additional infmation (recommended) Tick this box if wish to opt-out of the SCR Carers Infmation A carer is a friend family member who gives their time to suppt 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 who s suppt you could not manage without? Yes No If yes, what is their name and contact number? Do you consent f your carer to be infmed about your medical care? Yes No Do you look after suppt someone who couldn t manage without you? Yes No If yes, do you look after someone who is a patient of Nthfield Medical Centre? Yes No Don t know If yes, what is their name? Are they a: Relative Friend Neighbour Medical details *Are you allergic to any medicines? Yes No (if yes please specify) *List other allergies / intolerances (i.e. nuts, gluten, pollen, animal hair certain foods. Please mark none if you have no other allergies that you know of) (f women only) Have you had a cervical smear? Yes No (Please state where, when and the result if possible) 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 ( Emphysema) Yes Year Cancer Yes Year Osteoposis / Bone fractures Yes Year Rheumatoid Arthritis Yes Year Peripheral vascular disease Yes Year

3 Do you have any disabilities, illnesses accessibility needs? I.e. needing to be seen in ground flo consulting rooms use of a specific communication device such as a hearing aid? If yes, please tell us how we can suppt your needs. The Accessible Infmation Standard (AIS) Please use this space to tell us about any specific communication needs you have. I.e. needing infmation in large print deafblind telephone contact. F further infmation please visit Do you have family histy 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 disder Yes Who Stroke / CVA Yes Who Epilepsy Yes Who Asthma Yes Who Osteoposis Yes Who Please tell us about your smoking and exercise 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? F quit smoking suppt please call visit Are you an ex-smoker Yes No When did you quit? How many did you used to smoke a day? Do you exercise regularly? Yes No If so What exercise do you take? How often? Please recd any additional infmation about you that you think is imptant f us to know 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 me efficient and convenient f patients and staff. If you have already nominated a pharmacy, please tell us which pharmacy you have chosen. F further infmation about this service, please talk to your pharmacist of choice. *Signed *Date / / / Signed on behalf of patient (if applicable) (e.g. f mins under 16 years old, adults lacking capacity)

4 Please tell us about your alcohol consumption This is one unit of alcohol and each of these is me one unit AUDIT C Questions 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? Scing system less 2-4 times per month 2-3 times per week 4+ times per week Your sce How often have you had 6 me units if female, 8 me if male, on a single occasion in the last year? Scing: A total of 5+ indicates increasing higher risk drinking. An overall total sce of 5 above is AUDIT-C positive. Please fill in further questions overleaf if your sce is 5 above. SCORE

5 Sce from AUDIT- C (5 above) SCORE Remaining AUDIT questions Questions How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was nmally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the mning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt remse after drinking? How often during the last year have you been unable to remember what happened the night befe because you had been drinking? Have you somebody else been injured as a result of your drinking? Has a relative friend, doct other health wker been concerned about your drinking suggested that you cut down? Scing system No No Yes, but not in the last year Yes, but not in the last year Yes, during the last year Yes, during the last year Your sce Scing: 0 7 Lower risk, 8 15 Increasing risk, Higher risk, 20+ Possible dependence TOTAL Sce equals AUDIT C Sce (above) + Sce of remaining questions TOTAL A sce of 8 above indicates an increased risk. Please read the attached brief advice if your sce is 8 above.

6 NORTHFIELD MEDICAL CENTRE Application f online access to my medical recd Surname First name Address Date of birth address Telephone number Postcode Mobile Number I wish to have access to the following online services (please tick all that apply): 1. Booking appointments 2. Requesting repeat prescriptions 3. Accessing my summary recd I wish to access my medical recd online and understand and agree with each statement (tick) 1. I will be responsible f the security of the infmation that I see download 2. If I choose to share my infmation with anyone else, this is at my own risk 3. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible 4. If I see infmation in my recd that is not about me is inaccurate, I will contact the practice as soon as possible 5. 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. Signature Date F practice use only Patient NHS number Practice computer ID number Identity verified by (initials) Authised by Date account created: Level of recd access enabled Date Method Vouching Vouching with infmation in recd Photo ID and proof of residence Date Date passphrase sent: Prospective Notes / explanation Retrospective Detailed coded recd Limited parts GP Review of Electronic Recds Reviewing GP (Print Name):. Signature. Date:

7 Online Services Recds Access Patient infmation leaflet It s your choice If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions f any medications you take regularly and look at your medical recd online. You can also still use the telephone call in to the surgery f any of these services as well. It s your choice. Being able to see your recd online might help you to manage your medical conditions. It also means that you can even access it from anywhere in the wld should you require medical treatment on holiday. If you decide not to join wish to withdraw, this is your choice and practice staff will continue to treat you in the same way as befe. This decision will not affect the quality of your care. You will be given login details, so you will need to think of a passwd which is unique to you. This will ensure that only you are able to access your recd unless you choose to share your details with a family member carer. The practice has the right to remove online access to services. This is rarely necessary but may be the best option if you do not use them responsibly if there is evidence that access may be harmful to you. This may occur if someone else is fcing you to give them access to your recd if the recd may contain something that may be upsetting harmful to you. The practice will explain the reason f withdrawing access to you and will re-instate access as quickly as possible. GP appointments online Repeat prescriptions online It s Your Choice View your GP recds It will be your responsibility to keep your login details and passwd safe and secure. If you know suspect that your recd has been accessed by someone that you have not agreed should see it, then you should change your passwd immediately. If you can t do this f some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your passwd. If you print out any infmation from your recd, it is also your responsibility to keep this secure. If you are at all wried about keeping printed copies safe, we recommend that you do not make copies at all. The infmation that you can see online may be misleading if you rely on it alone to complete insurance, employment legal repts fms. Be careful that nobody can see your recds on screen when you are using Patient Online and be especially careful if you use a public computer to shut down the browser and switch off the computer after you have finished.

8 Befe you apply f online access to your recd, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following befe you are given login details. Things to consider Fgotten histy There may be something you have fgotten about in your recd that you might find upsetting. Abnmal results bad news If your GP has given you access to test results letters, you may see something that you find upsetting. This may occur befe you have spoken to your doct while the surgery is closed and you cannot contact them. If this happens please contact your surgery as soon as possible. The practice may set your recd so that certain details are not displayed online. F example, they may do this with test results that you might find wrying until they have had an opptunity to discuss the infmation with you. Choosing to share your infmation with someone It s up to you whether not you share your infmation with others perhaps family members carers. It s your choice, but also your responsibility to keep the infmation safe and secure. If it would be helpful to you, you can ask the practice to provide another set of login details to your Online services f another person to act on your behalf. They would be able to book appointments der repeat prescriptions. They may be able to see your recd to help with your healthcare if you wish. Tell your practice what access you would like them to have. Coercion If you think you may be pressured into revealing details from your patient recd to someone else against your will, it is best that you do not register f access at this time. Misunderstood infmation Your medical recd is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the infmation within your medical recd may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery f a clearer explanation. Infmation about someone else If you spot something in the recd that is not about you notice any other errs, please log out of the system immediately and contact the practice as soon as possible. Me infmation F me infmation about keeping your healthcare recds safe and secure, you will find a helpful leaflet produced by the NHS in conjunction with the British Computer Society: Keeping your online health and social care recds safe and secure

9 FOR OFFICE USE ONLY PHOTO ID TYPE: STAFF INITIALS (Over 18 only) ADDRESS ID TYPE: STAFF INITIALS REGISTRATION COMPLETED ON SYSTMONE STAFF INITIALS NEW PATIENT TEMPLATE COMPLETED ON S1 STAFF INITIALS DATE DATE ONLINE ACCESS PAPERWORK GENERATED STAFF INITIALS DATE PAPERWORK TO SCANNING STAFF INITIALS DATE Updated 20/10/17