Registration Form for New Patients

Please complete in BLOCK CAPITALS, and tick the boxes as appropriate:

For office use only

Proof of identity:		□ Driving licence        Proof of Residence: 

□ Passport  
□ Identity card

Visa seen:   		□ (exp. date…………..)	□ single entry	□ multi entry

Title:  Mr   □      Mrs   □	  Miss	 □    Ms □     Other (…………)	
First Name: 		Preferred Name:		
Surname:		Previous Surname:		
Date of Birth:		Marital Status:		
Home Address:		
		
Postcode:		
Home Telephone Number:		
Mobile Telephone Number:		
Email:		
Preferred Communication Method:		
NHS Number:		
Place of Birth (town/county)		

Have you ever been at this surgery before:	Yes		No		
Have you previously registered with a GP on the NHS:	Yes		No		
Name and address of previous GP:		

Your previous address and postcode while registered with previous GP:		

Postcode:		
		
If you are from abroad:		
Date you left the UK if previously a resident of the UK:		
Date you first came to live in the UK:		
Your first UK address:		

		
		
If you are returning from the Armed Forces:	
Enlistment date:		
Date of leaving Armed Forces:		
Your address prior to enlistment:		

Health Questionnaire

It often takes a few weeks to get your records from your previous GP. It would be helpful if you could answer the following questions so that we have some background knowledge of your health. Thank you.

	

Please List your current medications:		
Medication:	Dose:	
		
Drug Allergies:		
Please list any serious illness, operations or long-term health problems (EG: diabetes, blood pressure) that require medication:

Current Smoking Status:

Never smoked tobacco	

	

Cigarette Smoker	
	
Ex-Smoker	

Rolls Own Cigarettes	
	
Ex-rolled tobacco smoker	

Cigar Smoker	
	
Ex-cigar smoker

Pipe Smoker	
	
Ex-pipe smoker

Ex trivial smoker <1 a day

Ex-light smoker 1-9 a day

Ex-moderate smoker 10-19 a day

Ex-heavy smoker 20-39 a day

Ex-very  heavy smoker 40+ a day

Ex-smoker unknown amount

How many cigarettes/how many grams of tobacco do you smoke a day?	

Date Stopped Smoking:	

Female Patients Only:	

Date of last smear:	

Result:	

Date of last mammogram (age 50 or over):	

	

 

Alcohol

Recommend Safe Limits of Alcohol 

Men should drink no more than 21 units of alcohol per week (and no more than four units in any one day).
Women should drink no more than 14 units of alcohol per week (and no more than three units in a day).
Pregnant women.  It is known that a lot of alcohol can damage a developing baby.  A small amount probably does no harm.  However, the exact amount that is safe is not known.  Therefore, to play safe, advice from the Department of Health is that pregnant women and women trying to get pregnant should not drink at all.  If you choose to drink when you are pregnant then limit it to one or two units, once or twice a week.  And never get drunk.

What is a unit of Alcohol?
One unit of alcohol is:-
•	Half a pint of ordinary strength beer, lager or cider (3-4% alcohol by volume), or
•	A small pub measure (25ml) of spirits (40% alcohol by volume), or
•	A standard pub measure (50ml) of fortified wine such as sherry or port (20% alcohol by volume)

There are one and a half units of alcohol in:-
•	A small glass (125ml) of ordinary strength wine (12% alcohol by volume), or
•	A standard pub measure (35ml) of spirits (40% alcohol by volume)

0	
1	
2	
3	
4	
Your score	

How often do you have 8 (men)/6 (women) or more drinks on one occasion?	
Never	
Less than monthly	
Monthly	
Weekly	
Daily or almost daily	

Only answer the following questions if your answer above is monthly or less	

How often in the last year have you not been able to remember what happened when drinking the night before?	
Never	
Less than monthly	
Monthly	
Weekly	
Daily or almost daily	

How often in the last year have you failed to do what was expected of you because of drinking?	
Never	
Less than monthly	
Monthly	
Weekly	
Daily or almost daily	

Has a relative/friend/doctor/nurse been concerned about your drinking or advised you to cut down?	
No	
Yes but not in the last year	
Yes, during the last year	

Do you have a specific diet? Please specify:	

Have any of your blood relations suffered from the following:	

Condition	
Relative	
Age at onset if known	

Heart Attack	

Stroke	

High blood pressure	

Cancer	

Diabetes	

Asthma	

Other serious illness (please state)	

	

Next of kin

Title:  Mr   □      Mrs   □	  Miss	 □    Ms □     Other (…………)	
Name		
Address		
Relationship
		Email Address		
Telephone No		Mobile No		
Emergency contact	 	Yes / No	Can discuss record   	Yes / No                  	

Ethnicity

The Government requires us to collect data about the ethnic background of our patients. This information can help the Department of Health plan to meet the needs of the community and ensure that everyone has equal access to healthcare. Please note that we are not asking about citizenship or nationality but about the ethnic group to which you feel that you belong.

All the information we receive will be used and treated with confidence. All information released is CONFIDENTIAL and anonymous.

Completing this form is entirely voluntary. Your care at the surgery will not be affected by your decision to complete or not complete this form. If you have any questions about completing this form, please ask a member of staff. Otherwise, please complete the from below by ticking the box of the ethnic group you feel you belong to. If you feel you are descended from more than one group, please tick the one you feel you most belong to, or choose the “Any other ethnic group” box.

AO	White	British		
BO	White	Irish		
CO	White	Any other white background		
DO	Mixed	White and Black Caribbean		
EO	Mixed	White and Black African		
FO	Mixed	White and Asian		
GO	Mixed	Any other mixed background		
HO	Asian or British Asian	Indian		
JO	Asian or British Asian	Pakistani		
KO	Asian or British Asian	Bangladeshi		
LE	Asian or British Asian	Sri Lankan		
LO	Asian or British Asian	Any other Asian background		
MO	Black	Caribbean		
NO	Black	African		
PO	Black	British		
PD	Black	Any other Black background		
RO	Other ethnic groups	Chinese		
SO	Other ethnic groups	Any other ethnic group		
Main Language:

Internet Access (Patient Access)

Mitchley Avenue Practice offers internet access for booking appointments and requesting repeat medications.

What is Patient Access?

With Patient Access, you can now view, book and cancel appointments from home, work or on the move – wherever you can connect to the internet. What’s more, because Patient Access is a 24 hour online service – you can do this in your own time, day or night. Plus, Patient Access is not just for booking GP appointments, you can also order repeat prescriptions
 
How do I register?

If you would like to use Patient Access, please sign below and our reception staff will provide you with an access code. This can be collected from reception within 3 working days.

Is my information secure?

All information that is sent to your surgery via EMIS Access is secure. Your personal details are encrypted and protected using the highest standard internet security, so it cannot be intercepted. Only you and your GP surgery are able to see this information.

Please sign me up for Patient Access:

Name

Address
		
Date of Birth

		Email Address

	
Telephone No
		Mobile No		
Signature		Date		

Nominated Pharmacy

Name
	Address

		

Connecting your Care – Sharing Information

What information will be shared?
The information shared will include:
•	Name, address and NHS number
•	Appointments and hospital attendances
•	Important medical history, including diagnoses, medicines and allergies
•	Test results, such as blood tests and x-rays
What information will not be shared?
Certain information is classified as highly sensitive and is restricted by law, such as sexual health, assisted conception and adoption records and this information will not be shared.
Is my information safe?
Information about you is protected under the Data Protection Act 2018 and the General Data Protection Regulations 2016. This requires that health and social care professionals:
•	Can see information about you only so that they can provide you with the care that you need
•	Must keep your records secure
•	Have a duty of confidence
In addition, all organisations are governed by the General Data Protection Regulation 2016, which means they are responsible for your information and must keep it safe.
Information about you will not be shared with or sold to private companies.
Who will see the information about me?
Only the people directly involved in your care, at the time and place when you see them, or when they are preparing to see you or following up results, clinical letters or follow up care. This might be your GP or practice nurse, hospital doctors and nurses, along with administrators who might be arranging your appointments and care.
Our patients have a choice of course and you can opt out if you want to.
If you do not want your information to be shared, you have the right to opt-out by visiting www.swlondon.nhs.uk/connectingyourcare and downloading the opt-out form.