Register Online – Acrefield Surgery New Patient Registration Form (GSM1 + Health Q’s) If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form. Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number Optional First Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Female Male EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseFirst Spoken Language Town and Country of Birth Address Street Address Address Line 2 City Postcode Main Contact NumberHome Contact Number OptionalEmail Enter Email Optional Confirm Email Optional Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Optional Address Line 2 Optional City Optional Postcode Optional Name of doctor while at that address Optional Address of previous doctor Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional If you are from abroadYour first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional Supplementary QuestionsAre you ordinarily a resident in the UK? Yes No European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? Yes Optional No Optional DemographicsMarital Status Single, never married Married Civil Partnership Divorced Widowed Separated Which of the following options best describes you? Heterosexual or Straight Gay or Lesbian Bisexual Prefer not to say In another way Sex and gender identity – Which one of the following best describes how you think of yourself? Male (including trans men) Female (including trans women) Non-binary Prefer not to say In another way Is your gender identity the same as the gender you were given at birth? Yes No Prefer not to say Please specify the ethnic group you consider you belong to English Welsh Scottish Northern Irish British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say What is your main religion? No religion Optional Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional Buddhist Optional Hindu Optional Jewish Optional Muslim Optional Sikh Optional Other religion Optional Communication NeedsDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language? DisabilityDo you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) No known impairment, health condition or learning difference Optional A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional A learning difficulty Optional Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional Deaf or hearing impaired Optional Blind or have a visual impairment uncorrected by glasses Optional An impairment, health condition or learning difference that is not listed above Optional Prefer not to say Optional Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalArmed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes No Do you have access to secure housing? Yes No What is your current immigration status? Asylum Seeker Optional Failed Asylum Seeker Optional CarersDo you have caring responsibilities? None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say Do you have a carer? Yes No Emergency ContactFull Name Relationship to you Contact NumberAre they your next of kin? Yes No Do you give us permission to discuss your medical records with them? Yes No About YouHeight Weight Smoking Status Current Smoker Ex Smoker Never Smoked What do you smoke? e.g. Cigarettes, Vape, CigarsHow many do you smoke per day? Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per week OptionalAlcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) 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 Do you have any significant family history we should be aware of? OptionalMedical HistoryMajor Illnesses OptionalPlease include datesPast Operations OptionalPlease include datesFamily History Illnesses OptionalPlease include datesCurrent Medication OptionalWe routinely offer HIV screening would you be interested in being screened? Yes No Sight Good Poor Registered Blind Hearing Good Poor Partially Deaf Deaf Are you over 75 years old?The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.AllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include datesImportant Registration InformationFor anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations. You will soon receive an email from the practice with your log in details. These are confidential: It is your responsibility to ensure they can be received securely by email. Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing ServiceSummary Care RecordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? Yes No Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323What happens to my information?Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year
