new patient questionnaire · seascale health centre new patient questionnaire new patient...

Seascale Health Centre New Patient Questionnaire

New Patient Questionnaire

Please take the time to complete this questionnaire; it will help us to gather important

information to ensure we manage your most important health requirements.

Full Name Previous Surname(s)

Date of Birth Place of Birth

Tel. No Home Mobile No

Address

Email address

Other family members at this address

Next of Kin Name

Tel. No Home

Mobile No

Address

Relationship to you

Do they permission to discuss your record? Yes / No

Mobile Phone Consent

If you provide us with a mobile number you are automatically opted in to receive appointment reminders

and information messages via SMS from Seascale Health Centre.

Online Access

Would you like to be registered for online access to your records? Yes / No

Would you like to receive your instructions and pin number via e-mail? Yes / No

Please indicate your ethnic origin

Main Spoken Language

Carers: Do you look after someone or does someone regularly help you? Please give details below

Do you have any sensory impairments or communication needs that we should know about? i.e. wear

hearing aid, would like correspondence in large print?

Height in cm Weight in kg

Do you smoke? Yes No Ex-Smoker E-Cigarette

Cigs per day Date given up

Oz per day

A White B Mixed C Asian or Asian British

D Black or Black British E Chinese or other ethnic group

British White and Black Caribbean Indian Caribbean Chinese

Irish White and Black African Pakistani African Any other

Please specify Other White and Asian Bangladeshi Any other black background

Any other Mixed background Any other Asian


Family History: Do you have any family members who have had the following?

Relationship to you

Diabetes Y/N

Stroke Y/N

Thyroid Disease Y/N

Heart Attack Y/N

Asthma Y/N

Cancer Y/N

Glaucoma Y/N

Any other important family illnesses?

Do you have any allergies?

Have you been diagnosed with any of the following?

Diabetes Type 1 Diabetes Type 2 Chronic Heart Disease

Chronic Kidney Disease Cardiovascular Disease Asthma/COPD (Respiratory Disease

Cancer Stroke Epilepsy

Depression Dementia Other - Please Specify

Have you had any operations, major illnesses or medical conditions?

Date/Year Details

Are you on any repeat medication?

Drug Name Dosage Times taken daily

Do you have any health concerns at present?

Today’s date


Patient Name Date of Birth

Complete the 3 questions in AUDIT-C first. If the score is 5 or more the full AUDIT

questionnaire should be completed

AUDIT – C

Scoring system Questions

0 1 2 3 4

Your

score

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

AUDIT-C score

Scoring:

A total of 5+ indicates increasing or higher risk drinking in which case the remaining AUDIT questions

need to be completed.


Score from AUDIT- C (other side)

Remaining AUDIT questions

Questions Scoring system

Your

score 0 1 2 3 4

How often during the last year have you found

that you were not able to stop drinking once you

had started?

Never

Less

than

monthly

Monthly Weekly

Daily or

almost daily

How often during the last year have you failed to

do what was normally expected from you

because of your drinking?

Never Less than


Daily or

almost daily

How often during the last year have you needed

an alcoholic drink in the morning to get yourself

going after a heavy drinking session?

Never Less than


How often during the last year have you had a

feeling of guilt or remorse after drinking? Never

Less than


Daily

or almost daily

How often during the last year have you been

unable to remember what happened the night

before because you had been drinking?

Never Less than


Daily

or almost daily

Have you or somebody else been injured as a

result of your drinking? No

Yes, but not

in the last year

Yes, during

the last year

Has a relative or friend, doctor or other health

worker been concerned about your drinking or

suggested that you cut down?

No

Yes,

but not in the last year

Yes,

during the last year

Full total AUDIT Score

Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,

16 – 19 Higher risk, 20+ Possible dependence

For office use only:

Photo ID seen Code 9RN added to care history

Comments ………………………………………………………………………………………………….


Patient Agreement

Between:

Seascale Health Centre (including Bootle Surgery), Gosforth Road, Seascale, CA201PN

AND

Patient Name Date of Birth

Thank you for joining the Seascale Health Centre. This agreement outlines our commitment from us to

you as a patient. It also outlines our expectations from you. Having a mutual understanding of this

agreement will enable us to give you the best possible care.

Our Commitment

• To provide you and your family with the best possible primary health care.

• To treat all our patients and visitors to the practice with courtesy, respect and dignity at all times.

• To progress your treatment as efficiently as possible.

• To meet all our responsibilities with respect to confidentiality.

• To issue repeat prescriptions following approval by a GP, providing we are given 48 hours notice.

Your Commitment

• To afford us the same courtesy, respect and dignity as you expect from us.

• You will not undertake any abusive behaviour both verbal and physical towards any doctor or

member of staff.

• If you have grievances against any member of staff, you should make an appointment to see the

practice manager. You should not discuss your grievance with the member of staff concerned.

• You will not present at the surgery and expect to be seen by a doctor or nurse immediately unless

you have a life-threatening complaint. You should otherwise make an appointment to be seen in

the usual way.

• You will behave in an acceptable way in the Reception area when attending the surgery, taking

account of other patients around you.

• You will be prepared to see any member of the practice team. You cannot insist on particular

members of staff carrying out any specific duties.

• You will advise us if you cannot keep an appointment.

• You will only request a home visit, if absolutely necessary.

• You will use a telephone consultation whenever possible, especially for test results.

• To remember doctors are human too and they cannot always solve all your problems.

• To contact the practice manager directly with any complaint.

AGREEMENT

If it is felt that your behaviour is inappropriate, our staff will:

• ask you to leave the premises

• if necessary we will seek police assistance

• consider removing you from the list

Please note that all of the above is what we would normally expect from all our patients

Understood and agreed by:

Patient Name Signature

Doctor Name Signature

Practice Manager Name Signature

Date


NHS Record Sharing

Seascale Health Centre Practice Data “Opt Out” Form

Please complete the form below if you wish to opt out from NHS Record Sharing. Information about this

is available on our website or from reception.

Patient Name

Date of Birth

Address

I am the patient (or guardian of the patient) named above. I have read the patient information and have

decided that I do not wish to share my Record with other Health Care Professionals. (Please tick

appropriately below)

Your GP records (EMIS) Signature

Summary Care Record (9Nd0) Signature

(National within the NHS)

Care Data (9Nu0)(Data only) Signature

Dissent from secondary use of general practitioner patient identifiable data.

By signing this form I understand that my GP Practice will disable sharing of my Medical record and as a

result only health care professionals working in my practice will have access to my medical records.

Patient Signature Date

Office: Coded by Date


Application form for access to the practice online services.

Before you apply for online access to your record, there are some other things to consider.

Although the chances of any of these things happening are very small, you are asked that you have read

and understood the following before you are given login details.

Things to consider

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting.

This may occur before you have spoken to your doctor or while the surgery is closed and you cannot

contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers.

It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against

your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best

possible care. Some of the information within your medical record may be highly technical, written by

specialists and not easily understood. If you require further clarification, please contact the surgery for a

clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the

system immediately and contact the practice as soon as possible.

More information

For more information about keeping your healthcare records safe and secure, we recommend that you

read

Protecting your GP Online Records

https://www.england.nhs.uk/wp-content/uploads/2016/11/pat-guid-protecting-your-records.pdf

and this helpful leaflet produced by the NHS in conjunction with the British Computer Society:

Keeping your online health and social care records safe and secure

https://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/PatientGuidanceBooklet.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/11/pat-guid-protecting-your-records.pdf

https://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/PatientGuidanceBooklet.pdf


First Name Surname

Date of Birth Place of Birth

Tel. No Home Mobile No

Address

Email address

I understand that my email address and/or mobile number may be used by the practice to contact you to

provide health and care services. For example:

appointment reminders

health campaign messages

messages relating to your own health and care e.g. test results

surveys about our services

If you do not wish to be contacted by either of the following please tick:

Email

Mobile

I wish to have access to the following online services (please tick all that apply):

1. Booking appointments □

2. Requesting repeat prescriptions □

3. Sending secure messaging □

4. Access to detailed medical record □

5. Proxy Access to records for family members who I care for with separate login details □

I wish to access my online services and understand and agree with each statement (tick)

1. I have read and understood the information provided by the practice □ 2. I will be responsible for the security of the information that I see or download □ 3. If I choose to share my information with anyone else, this is at my own risk □ 4. If I suspect that my account has been accessed by someone without my agreement, I will

contact the practice as soon as possible

□

5. If I see information in my record that is not about me or is inaccurate, I will contact the

practice as soon as possible

□

6. 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.

□

7. If I see something in my records that I am unsure of and have not yet been contacted by

the surgery, I will wait until usual opening times and not contact the out of hours or

emergency services

□

Signature Date

For Office Use Only Date clinical assurance completed

Date account created Assured by (initials)

Date account details given Reason for refusal if applicable

Level of access created

Detailed coded record □

All prospective □

All retrospective □