Registration Form ( Adults)

Last Updated: 02/09/2022

Your Contact Details

Title

Gender *

Female

Male

First Names *

Surname *

Date of Birth *

Previous Surname

Town and Country of birth *

NHS Number *

Home Address *

Postcode *

Home Telephone Number

Mobile Number *

Email Address *

Previous GP

Please help us trace your previous medical records by providing the following information

Name and Address of Previous GP *

Your previous address in the UK *

If you are from abroad - date you first came to live in uk *

If you are returning from the armed forces

please indicate if you have ever served in the uk armed forces and/or been registered with a ministry of defence GP in the UK or overseas:

Regular

Reservist

Family Member

ADDRESS BEFORE ENLISTING

SERVICE OR PERSONNEL NUMBER

ENLISTMENT DATE

If you need your doctor to dispense medicined and appliances*

*Not all doctors are authorised to dispense medicines

If you need your doctor to dispense medicined and appliances*

I live more than 1.6km in a straight line from the nearest chemist

i would have serious difficulty in getting them from a chemist

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor resister as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Thick here if you have given blood in the last 3 years

Yes No

My preferred address for donation is : (only if different from above, e.g. your place of work)

Information About You

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details (name, contact number)

Are you a carer? *

Yes No

(If yes please give details)

Key Support Worker

Do you have a key Support Worker? *

Yes No

If yes, do you consent for us to contact your Key Support Worker?

Yes No

Please provide Key Support Worker details (name, contact number)

Women

Have you ever had a cervical smear?

Yes No

If 'yes', please state when, where and the result

Children

Please tell us if you have any children and how many? *

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of kin

Who to contact in case of emergency

Name of next of kin *

Surname of next of kin *

Gender of next of kin *

Male

Female

Contact number of next of kin *

Email address

Relationship to patient *

Does your next of kin lives under same address as you? *

Yes No

Is your next of kin registered with us? *

Yes No

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

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

HIV Screening

Would you like to be screened for HIV? *

Yes No

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Proof of Identity and Address Provided

Patient access to online services

Terms and Conditions : The Practice will not allow misuse of the online system and will monitor usage by individual patients. Where it is considered that a patient is misusing the system, access will be blocked.

Please select if you wish to obtain online access to *

Allergies and Medication

Immunisations History

Results (including: blood test results, urine, swabs, BP readings etc.)

Problems (including present and past medical history)

none of the above

Nomination of pharmacy for EPS

EPS (Electronic Prescription Services)

Would you like to nominate a pharmacy for your EPS? *

Yes No

Hiren - Next door pharmacy *

Yes No

Other pharmacy? Please specify Name and Address *

Signature

Signature *

Date *

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Registration Form ( Adults)

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