Microsoft word - 79935_2 registration.doc

Welcome to Princess Street Group Practice.
Please carefully complete this registration form. Your answers will help us to plan services that can help to improve your health. If you have any problems completing this form please ask reception for help. We may have some questions to ask you regarding your answers so a member of the reception team will go through your completed form with you. We will then give you a copy of our practice leaflet and any other relevant information. The receptionist will also be able to help you if you need to book any appointments. PERSONAL DETAILS (Please complete in block capitals and 9as appropriate)

Family Name: . Former Family Name: . …
First Name: . Middle Name(s): .
Title: Mr † Mrs † Miss † Ms † Other † (please state)…………………………………….
Gender: Male † Female † Date of Birth: .
NHS Number: (If known) .…………
Current Address: Flat Number……………… Flat Name………………………………….………
House Number………………………… Road Name . Postcode:.
Home telephone: .† Work telephone: . †
Mobile telephone: ………………………….† E-Mail address: ………….……….……….†
Please indicate (by ticking) which number you would prefer us to contact you on during the day The practice will send text message reminders to your mobile. If you prefer not to receive these please tick † The next questions will help us to establish if you have any previous NHS medical records
and assist us in tracing those records. Please give as much information as possible.
Place of Birth: ……………………. Year you first came to UK (if applicable): .
If you were previously a resident in the UK, give the year you left: .
Name of your previous GP in UK :.…………………………………. No previous GP in UK †
Your last home address: Flat Number………………….Flat Name………………………………….
House Number…………………………Road Name……………………………………………………… Town/City…………………….…………Postcode………………………………………………………… Name of Next of Kin:…………….……………….Relationship to you: .
Next of kin contact telephone: .………Next of kin town of residence: ………………….
Is your Next of Kin registered at this practice? Yes † No †
Signature:
. ……………Date:………………………………………….

FOR PRACTICE USE ONLY
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Form checked
Information given:
Entered by:
Date entered:
Number:
by:
Please continue over the page. Page 1 of 6. August 09 WHAT IS YOUR ETHNIC GROUP?
† Prefer not to state ethnic group
White
Asian or Asian
Black or Black
Other ethnic
Do you need us to book you an interpreter for your appointments? † Yes † No YOUR MEDICAL HISTORY
Have you had or do you now have any of the following illnesses?
Please tick the box if you have ay of the
DETAILS
following Illnesses
diagnosis
depression, schizophrenia) Other important illnesses or Please continue over the page. Page 2 of 6. August 09 FAMILY MEDICAL HISTORY

Please give us some information about your family
Any
If Yes, please
Age at If they have died,
illnesses?
describe
what was the cause
of death?
Brothers &
Sisters
4.
MEDICATION

Are you on any regular medication? Yes/No
If you have ticked YES please ask reception to book you an appointment to see a doctor before your next supply is due. We are unable to issue any prescriptions until you have discussed your medication with the GP. If you have Asthma please make an appointment with our Asthma Nurse
Do you have any drug allergies Yes/No
If yes, please list what these are
YOUR HEALTH

What is your weight? .What is your height? .
Regular exercise and a good diet help to keep your heart healthy. Ask us for advice. When did you last have your blood pressure measured? Date:
Do you know what your reading was? ………/……. or Normal … Abnormal
If you are aged 45 or over you should have your blood pressure checked every 5 years. If your last blood pressure check was abnormal or if you cannot remember the result please make an appointment to see the Health Care Assistant to get it checked.
Do you drink alcohol? Yes/No
If yes, how many units do you normally drink per week? .
(One unit = half a pint of beer or 1 glass wine or 1 single measure of spirits)
More than 21 units per week for men and 14 for women can damage your health. Ask a doctor or nurse for more advice. Please continue over the page. Page 3 of 6. August 09
To help us to provide you with further advice can you please answer the
following questions about your alcohol use:

Men: how often do you have EIGHT or
more drinks on one occasion. Women: How
often do you have SIX or more drinks on
one occasion? How often during the last year have you drinking? How often during the last year have you failed to do what was normally expected of In the last year has a relative or friend, or a concerned about your drinking or suggested Yes, on more than one occasion † you cut down?
Do you currently smoke?

If yes, how many cigarettes do you smoke every day? .
Have you ever smoked?
If so, how many did you smoke every day before you stopped? .
Tobacco smoking is the biggest cause of preventable illness and death. If you want
help to stop please ask for an appointment with a smoking cessation advisor.
CONTRACEPTION AND SEXUAL HEALTH

Do you use contraception? Yes/No
What do you use?
We offer a full range of contraception, including emergency contraception (the ‘morning
after’ pill). Ask any of our doctors or nurses. 1 in 10 young people in Southwark have a
sexually transmitted infection. Very often people do not know they are carrying this. If
you would like to have a sexual health screen please ask our reception team. .
Please continue over the page. Page 4 of 6. August 09 This section is for women only to complete
Women who are sexually active and aged between 25 and 64 should have a cervical
smear test every 3 years. This can prevent cancer in later life. In the UK we have a
national screening programme that invites women to have their smears done.

Have you ever had a smear?
Yes † No †
What was the date when you had your last smear done? . If your smear test is due or you are 21 or over and have never had a smear test please book
an appointment with a Practice Nurse.
REGISTRATION DETAILS
This information will help us to plan our services to meet the needs of our patients

Are you:
CARER DETAILS
A carer is a person who looks after a relative, friend or child with a physical or learning
disability; or who has a mental health problem, a long-term illness or who is frail. This definition
does not include those who are paid carers.
Are you a carer? Yes/No
Do you have a carer? Yes/No
Your carers name: .
Your carers telephone number: .
Please continue over the page. Page 5 of 6. August 09 DONOR INFORMATION
If you would like to donate blood and/or be an organ donor please complete the following and we can add your details to the registers. We are unable to do this unless you sign the relevant section(s). NHS Blood Donor Registration
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be
prepared to donate blood.
Tick here if you have given blood in the last 3 years †
Signature confirming consent to blood donation

For more information, please ask for the leaflet on joining the NHS Blood Donor Register
My preferred address for donation is: (only if different from above, e.g. your place of work)
__________________________________________________________ Postcode:_________________
NHS Organ Donor Registration
I would like to join the NHS Organ Donor Register as someone whose organs may be used for † Kidneys † Heart † Liver † Corneas † Lungs † Pancreas † Any part of my body Signature confirming consent to organ donation
For more information, please ask for the leaflet on joining the NHS Organ Donor Register


THANK YOU FOR COMPLETING THIS FORM

Your registration should take 3-5 days to process. If you need to make an
appointment to see one of our team sooner than this, please speak to a
member of the reception team who can book you an appointment. If you
have not had a practice leaflet please ask for one at reception.
FOR PRACTICE USE ONLY
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Please continue over the page. Page 6 of 6. August 09

Source: http://www.princessstreetgrouppractice.co.uk/practices/princessstreet/New-Patients-Registration-Form.pdf