Fleming Place e Blackridge EH48 3SS

Telephone 01501 751238 REGISTRATION FORM Welcome to Blackridge Health Centre. We wish you good health and contentment. If you ever need help from our staff, we will try to assist you as promptly and effectively as possible. Our whole team at Blackridge Health Centre is committed to establishing and maintaining the highest degree of physical and mental well being for you, your family and the local community. Please help us by completing this health registration form, with as much detail as possible. All information contained in this form will be kept confidential and secure by the Health Centre. PART 1: PERSONAL

Surname: First Name: Title: Address: Postcode: Date of Birth: Ethnicity: Home Tel: Email: Mobile: Consent for text contact? Yes / No Next of kin: Relationship: Contact No. ………………………………………………………………………………………………………………………… Your Occupation: Work Tel.: Are you a military Veteran? Are you a designated Carer? Yes / No If so, for whom?

PART 2: PRESENT HEALTH HISTORY 2.1 Is there any family history of illness? E.g. Heart Trouble, Epilepsy, High Blood Pressure, Stroke, Kidney Trouble, Diabetes, Glaucoma, Tuberculosis, Mental Illness, Cancer If yes, please detail: Yes / No 2.2 What medication & dose do you take? Please include contraception. 2.3 Are you allergic to any medicine? Yes / No If yes, please detail: 2.4 How many days a week do you undertake physical activity (everything counts)? For how long? 2.5 What is your smoking history? Never / ex-smoker / smoker: how many cigarettes? 2.6 How much alcohol do you consume per week? (1 unit = ½ pint or 1 spirit measure) 2.7 Please estimate your height and weight: 2.8 When did you last have a ‘Flu vaccination? Have you had Pneumococcal vaccination? 2.9 (Females only): When was your last cervical smear? Your last mammogram? What is your Obstetric History? (Childbirth)

STAFF USE: Height: Weight: BMI: BP: Signed:

Staff Use: Advised?

PART 3: Please give your PAST MEDICAL HISTORY. Have you had any of the following conditions?

NUMBER & CONDITION YES NO PLEASE GIVE DETAILS (Quote condition number)

1. Angina or heart disease / failure? 2. Stroke or CVA? 3. High blood pressure? 4. Thyroid or gland trouble? 5. Diabetes? (insulin, tablet or diet) 6. Depression or mental illness? 7. Lung disease or chronic Bronchitis? 8. Asthma? 9. Epilepsy, fits or blackouts? 10. Any form of cancer? 11. Kidney failure or problem? 12. Bladder problem? 13. Jaundice or liver disease? 14. Anaemia? 15. Allergies or hay fever? 16. Eczema or Dermatitis? 17. Psoriasis or any skin complaint? 18. Gastric or Duodenal Ulcer? 19. Gut or Bowel Problem? 20. Irritable Bowel Syndrome? 21. Colitis, Diverticulitis or Gallstones? 22. Hernia? 23. Breast disease? 24. Reproductive system problem? 25. Backache, slipped disc or Sciatica? 26. Limb weakness or pain? 27. Arthritis or bone / joint problem? 28. Eye disease? 29. Ear problem or hearing difficulty? 30. Headaches or migraines? 31. Stress or anxiety? 32. Serious injuries? 33. Surgical operations? 34. Tropical diseases? 35. Any illness or injury not mentioned? 36. Any significant hospital treatment? 37. Any x-rays, ECG or other tests? 38. Are you attending hospital outpatients?

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I confirm to the best of my knowledge & belief that the above statements are true. Please note: Our staff have the right to work in a safe environment without fear of intimidation, abuse, or

assault. We will not tolerate any verbal or physical threat towards any staff member or patient within the Health Centre. In signing this form, you are committing yourself to appropriate behaviour. Please discuss this with our staff if you have any questions or concerns. Please refer to our Health Centre leaflet for further details.

Signature of applicant: _________________________________ Date: ____ / _____ / ___________

STAFF USE:

The applicant is accepted onto the list of patients registered at Blackridge Health Centre. Signature of Clinician: Date:

Vision Online - Patient registration form If you would like to register for this online service please complete the form below and return it to your practice in person, along with a valid form of identification, for example photo ID or your passport. Once you are registered the practice will give you the information that will enable you to create a username and password.

Patient details Please complete in BLOCK CAPITALS Patient forename Patient surname Date of birth D D / M M / Y Y Y Y Email address This email address will be used by your practice to send you notifications and reminders.

Mobile number Signature

Date D D / M M / Y Y Y Y Completing the form on behalf of the patient? Print forename Print surname Relationship to patient

Signature

Date D D / M M / Y Y Y Y -----------------------------------------------------------------------------------------------------------------------------------------

Staff use only Patient ID seen Type of ID Staff name Date D D / M M / Y Y Y Y

About Vision online services We will be offering an online service for our patients so you can book your appointments and order your repeat prescriptions online at your convenience. Online appointment booking Have the flexibility to book and cancel your appointments from home, at work or any location with internet access. You don’t need to queue at the practice, wait on the telephone and you can manage your appointments outside practice opening hours. Request your repeat prescriptions online Request your repeat prescriptions quickly online by logging into your account and simply ticking the appropriate boxes. You can review the progress of your repeat prescriptions and any message that the practice may have sent to you. We are currently looking for interest in the service and will be registering patients for a start date towards the end of 2015 beginning of 2016. Please complete the note of registration form to note your interest and fill out and sign the Terms and Conditions details attached.

If you are interested in finding out more about the Vision clinical system we use at our GP practice please visit www.inps.co.uk.

Name: Date of birth: What is your ethnic group? Choose ONE section from A to E, then please tick appropriate box to indicate ethnic group. A: White White British, please state nationality

White Irish Any other white background, please state B: Mixed White and Black Caribbean White and Black African White and Asian Any other mixed background, please state C: Asian or Asian British

Indian

Pakistani Bangladeshi Any other Asian background, please state D: Black or Black British

Caribbean African

Any other Black background, please state E: Chinese or another ethnic group Chinese Any other, please state Not stated Main language spoken: _______________________ Do you require an interpreter? Yes / No

Collecting information about your ethnic group Everyone belongs to an ethnic group so all our patients and service users are being asked to describe their ethnic group. We are collecting this information to help the NHS and social services:

• Understand the needs of patients and service users from different groups and so provide better and more appropriate services for you.

• Identify risk factors – some groups are more at risk of specific diseases and care needs so ethnic data can help threat patients and support service users by alerting staff to high-risk groups.

• Improve public health by making sure that our services are reaching all of our local communities and that we are delivering our services fairly to everyone who needs them.

• Comply with the law as the Race Relations [Amendment] Act 2000 gives public authorities a duty to promote race equality and good race relations. Ethnic monitoring is important in making sure that race discrimination is not taking place.

The 16 ethnic groups used are standard categories for collecting ethnic group information. Using these codes will help us compare information about the groups using our services with information from the census, which tells us about our local population. The list of groups is designed to allow most people to identify themselves. The list is not intended to leave out any groups, but to keep the collection of ethnic information simple. It is important to us that you are able to describe your own ethnic group. If you need to complete any of the boxes labelled ‘any other group’ then please give some details so we can better understand your needs. You do not have to complete the questionnaire but providing the information is very important. It will help us with diagnosis and assessment of your needs, and social services have strict standards regarding data protection and your information will be carefully safeguarded. If you have any concerns or questions regarding this request, please contact the Health Centre Manager.