New patient registration form

Patient Registration and Health Questionnaire Form

Your contact details

NHS Number(Required)

Get help to find your NHS number online

Title(Required)

Please enter your title

Name(Required)

First Names Surname

Previous surname (if applicable)

Date of Birth(Required)

Male/Female(Required)

Male

Female

Current home address (inc. flat number if appropriate)(Required)

Current postcode(Required)

Home Telephone

Mobile Telephone(Required)

Work Telephone

Email(Required)

Enter Email Confirm Email

I consent to be contacted by email at this address*

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details. Please choose whether you consent to emails and SMS texts below:(Required)

Consent for Emails

Consent for SMS texts

DO NOT consent to Emails

DO NOT consent to SMS texts

Your Town and Country of birth(Required)

Have you returned to the UK from abroad?(Required)

Yes

Please give the date you left the UK

Please give the date of your return to the UK

Are you registering with the NHS for the first time in the UK?(Required)

Yes

Please give the date you came to the UK

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

You only need to complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

I live in another EEA country, or I have moved to the UK to study or retire, or I live in the UK but work in another EEA member state.

Yes

Do you have a non-UK EHIC or PRC?

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes

If yes, please enter details from your EHIC or PRC below:

3: Name(Required)

Country Code(Required)

4: Given Names(Required)

5: Date of Birth(Required)

6: Personal Identification Number(Required)

7: Identification number of the institution(Required)

8: Identification number of the card(Required)

9: Expiry Date

PRC validity period (a) From:

PRC validity period (b) To:

Supplementary questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

Are you ordinarily resident in the UK(Required)

Yes

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following options(Required)

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

I agree to the statement above

A parent/guardian should complete the form on behalf of a child under 16.

S1 Form

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

Yes I have an S1 form

Please give your S1 form to the practice staff. How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Your next of kin

Next of kin name(Required)

First Last

Relationship to you:(Required)

Contact number:(Required)

Other details

Please confirm who else lives at your current home address(Required)

Please provide their full name, date of birth and their relationship to you.

Please enter your previous address(Required)

Please help us trace your previous medical records by providing this information.

Previous postcode(Required)

Previous GP name and address(Required)

Please help us trace your previous medical records by providing this information.

Were you ever registered with an Armed Forces GP?

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable)

About you

Your Ethnicity(Required)

Your Religion(Required)

Your Housing(Required)

Your Employment(Required)

Communication needs

What is your first language?(Required)

Do you need an interpreter?(Required)

Yes

Language of interpreter

Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record.

Do you have a learning disability?(Required)

If yes, please request a Learning Disability Tool form

Yes

Carers

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Are you a carer?(Required)

Yes - Informal/Unpaid carer

Yes - Occupational/Paid Carer

Name of the person you care for:

First Last

What is your relationship with the person you care for?

DOB of the person you care for:

Address of the person you care for:

Telephone number of the person you care for:

NHS number of the person you care for:

Are you being cared for?(Required)

Yes

Name of your carer:

First Last

What is your relationship with your carer?

DOB of your carer:

Address of your carer:

Telephone number of your carer:

NHS number of your carer:

If you consent to your Carer being informed of any medical information about you which is held at the practice, please check the box below; if NOT leave blank

I am happy for my carer to be informed of any medical information about me which is held by the practice.

Medical information

Have you suffered from any of the following conditions?(Required)

Please state the type of cancer

Please let us know which mental health problem you suffer from or have received treatment for in the past

Depression

OCD

Anxiety

Bipolar disorder

Please state the year when you were first diagnosed (or approximate date)

Do you have any other mental health problems? If yes, please state these below

ALLERGIES: Please list any allergies or sensitivities you have including drug allergies below(Required)

Please enter 'N/A' if you have no allergies to report

Please list any immunisations or vaccinations you have had

Any other conditions, operations or hospital admission details:

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

Family history

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Please give any details if you have ticked any of the above

Current medication

Please check and include as much information about your current medication below Please give us your previous repeat medication list if possible and a medication review appointment may be needed(Required)

Please enter 'N/A' if taking no medication

Your lifestyle

Please give the number of hours exercise per week(Required)

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

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?(Required)

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption – Part Two

Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?(Required)
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?(Required)
Never
Less than monthly
Monthly
Weekly
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?(Required)
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?(Required)
Never
Less than monthly
Monthly
Weekly
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?(Required)
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

Have you or somebody else been injured as a result of your drinking?(Required)
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?(Required)
No
Yes, but not in the last year
Yes, during the last year

Score - part 2
0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

Smoking

What is your smoking status?(Required)
Never smoked
Ex-smoker
Smoker

Do you use an e-Cigarette?(Required)
No
Ex-user
Yes

How many cigars/ cigarettes or e-cigarettes do you smoke per day?

Would you like advice/help on quitting?
Yes
No
For further information please see: www.nhs.uk/smokefree

Height and weight

Your height:(Required)

Your weight:(Required)

Waist circumference

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? If yes, please give the date below.

Have you had a pneumococcal vaccination? If yes, please give the date.

Women only

Do you use any contraception?
Yes
No
If needed, please book an appointment

Do you have a coil or implant in situ?
Yes
No

Date inserted

Are you currently pregnant or think you may be?
Yes
No

Expected due date

Have you had any children?
Yes
No

Please give the dates of birth of your children

Have you had a hysterectomy?
Yes
No

When was the date of your hysterectomy?

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination
Yes
No
Unsure

I am less than 25 years old and have had a Meningitis C Vaccination
Yes
No
Unsure

Protected characteristics (Equality Act 2010)

All the information given on this form will be kept in the strictest confidence, as part of your medical records.

Please only complete those sections you feel confident in completing or you feel are appropriate for the age of the patient. Please note that this information is helpful to our clinicians to allow them to provide you with the best quality and individualised service that we can offer.

At birth were you described as (please tick one option)
Male
Female
Intersex
Prefer not to say

Which of the following describes how you think of yourself? (please tick one option)
Male
Female
Other
If you choose Other, please describe how you think of yourself in another way.

Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery).
Yes
No

Continuing to think about these examples, which of the following options best applies to you? Please tick one option
I am thinking about going through this process
I am currently going through this process
I have already been through this process
I have been through this process, then changed back
None of the above
I prefer not to say

Which of the following describes how you think of yourself? (tick all that apply)
Trans man
Trans woman
Transsexual person
Gender variant person
Cross dressing person
Transvestite person
Intersex person
In another way
I prefer not to say

I think of myself in another way as described here

Sexual orientation

Sexual orientation
Heterosexual or Straight
Gay or Lesbian
Bisexual
Do not know or not sure
Prefer not to say
Other

Electronic prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:

Living will

Do you hold a living will?
Yes
No
(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

NHS Organ and blood donation

Organ donation in England has changed to an opt out system. You still have a choice whether or not you want to become an organ donor. We will always ask your family to support your decision. So whatever you choose, it's really important that you let them know. More about the donation laws in England

Your choice to opt in or out
I am already registered as a donor
I wish to be a donor - all body parts
I wish to be a donor - for certain body parts
I do not wish to be a donor

Please provide details

To register: Online: www.blood.co.uk/the-donation-process/recognising-donors Telephone: 0300 123 23 23 to speak to an advisor who will send out a donor card.

NHS patient information sharing - Summary Care Record

If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
This section of the form covers the Summary Care Record. If you would like to know more about these things, please see the following link: NHS Health Records

NHS Summary Care Record(Required)
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Express consent for medication, allergies and adverse reactions only
Express consent for medication, allergies, adverse reactions and additional information
Express dissent for Summary Care Record (Opt out) – Patient does not want a summary care record and fully understands the risks involved with this decision. Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

NHS Patient information sharing - GP records

When you visit an NHS or social care service, information about you and the care you receive is recorded and stored in a health and care record. This is so people caring for you can make the best decisions about your care.
Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. If you would like to know more about these things, please see the following link: NHS Health Records

Do you consent to your GP Practice sharing your health record with other organisations who care for you?(Required)
Yes
No

Do you consent to your GP Practice viewing your health record from other organisations that care for you?(Required)
Yes
No

Online Access

You can find more information on how to register online on our website.

Signature

Date and signature

(you will be asked to sign this form when you visit the practice and provide ID and proof of address)

Please enter your full name(Required)

Today's date
Day
Month
Year

Not for urgent medical help(Required)
Yes, I understand this form is NOT for urgent medical help

Name
This field is for validation purposes and should be left unchanged.

Patient Registration and Health Questionnaire Form

Your contact details

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

If yes, please enter details from your EHIC or PRC below:

Supplementary questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

S1 Form

Your next of kin

Other details

Were you ever registered with an Armed Forces GP?

About you

Communication needs

Carers

Medical information

Family history

Current medication

Your lifestyle

Alcohol consumption - How many units of alcohol do you consume in a week?

Alcohol consumption – Part Two

Smoking

Height and weight

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Women only

Students only

Protected characteristics (Equality Act 2010)

Sexual orientation

Electronic prescribing

Living will

NHS Organ and blood donation

NHS patient information sharing - Summary Care Record

NHS Patient information sharing - GP records

Online Access

Signature

Date and signature

Helpful links

Part of Newcastle North PCN Limited