New Patient Questionnaire (16+ Years)

Last Updated: 30/06/2023

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Occupation

What is your occupation?

SMS Messaging Consent Preference

Can we contact you via text message? *

Yes No

Ethnicity

Special Circumstances

Communication Needs:

Please tick if any of the following apply and provide further details:

I have communication difficulties

Registered blind or partially sighted

Registered deaf

Registered disabled

Please specify any other details regarding the above question:

Main Spoken Language

Patient's Main Spoken Language *

Do you need an interpreter? *

Yes No

If an interpreter is needed, please specify

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. *

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 many units of alcohol do you drink on a typical day when drinking? *

How often have you drunk more than 8 units (men) or 6 units (women) on a single occasion in the past year? *

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

Next of Kin

First Name

Surname

Date of Birth

Address

Postcode

Home Telephone Number

Mobile Telephone Number

Email Address

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

NHS App

We recommend all our patients over 16 years of age, who have access to a smart phone, download the NHS App from their provider’s App Store.

The NHS App gives you the ability to book appointments, request prescriptions, view your health records and much more. If you require any assistance or further information, please visit: https://www.nhs.uk/nhs-app/

Local Shared Electronic Record

The NHS in England has introduced the Summary Care Record, which is used in emergency care. The record will only contain 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 your 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, healthcare staff treating you will have immediate access to important information about your health.

Station House Surgery is supporting Summary Care Records, but as a patient you have a choice. Please select from the options below.

For more information, please visit: https://digital.nhs.uk/services/summary-care-records-scr, or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020.

I want a Summary Care Record

Yes No

Signature

Signature *

Date *

Sharing your Data for anything other than our Personal Care & The National Data Opt-out:

Patients’ personal confidential data is extracted and shared with NHS Digital to support vital health and care planning and research.

Further information about how your data is shared can be found at

https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/general-practice-data-for-planning-and-research

Patients may opt out of having their information shared for Planning or Research by applying a National Data Opt Out and/or a Type 1 Opt Out.

See below or go to the NHS website for more information:

https://www.nhs.uk/your-nhs-data-matters/

National Data Opt-out (opting out of NHS Digital sharing your data with other organisations)

How to apply for National Data Opt-Out:

1. Go to https://www.nhs.uk/your-nhs-data-matters/manage-your-choice/. It will be useful to have your NHS number and an up-to-date email address or mobile phone number in your GP record which will be used to identify you.

2. Call the NHS Digital Contact Centre on 0300 303 5678, Available Monday to Friday between 9am and 5pm (excl Bank Holidays).

3. Download the National Data Opt-out form:

https://assets.nhs.uk/prod/documents/Manage_your_choice_1.1.pdf which you can complete and return by Post.

You can also make or change a choice for your children under the age of 13, or for someone you can legally make decisions for (You must have legal authority to make a choice for someone else, e.g. by Power of Attorney). These are both done by post, you can download the forms on the NHS website: https://www.nhs.uk/your-nhs-data-matters/manage-your-choice/other-ways-to-manage-your-choice/.

The practice is not able to process your National data opt-out for you.

Type 1 Opt-out (Opting out of NHS Digital collecting your data)

How to apply for Type 1 Opt-out:

1. Print out and complete the Type 1 Opt-out form at:

https://www.nhs.uk/using-the-nhs/about-the-nhs/opt-out-of-sharing-your-health-records/, and return the form to our Reception Team

2. Ask for a printed form to complete from our Reception Team

If you have previously Opted-out but would like to now Opt-In, use the same form as above.

You can register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient).

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New Patient Questionnaire (16+ Years)

Further Information