Adult New Patient Registration Westbury Adult New Patient Registration (Ages 18 and over) – Westbury Avenue Patients Registration Form (Adult) – Westbury Avenue Step 1 of 8 12% Westbury Avenue Registration Form Please upload one form of Photo ID and one form of Proof of Address as per these criteria. Please upload your ID and proof of address Drop files here or Select files Max. file size: 50 MB. 1. Background DetailsContact DetailsNHS Number Optional TitlePlease SelectMrMsMrsMissMxFirst Name First Surname Last Previous Surname (if applicable) Optional Gender Date of Birth DD slash MM slash YYYY Home Telephone OptionalWork Telephone OptionalAddress Street Address Address Line 2 City Postcode Previous Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Mobile NumberI consent to be contacted* by SMS on this numberEmail Address I consent to be contacted* by email Next of KinNext of Kin Name First Last Contact NumberRelationship to you Family Registered with us Optional Has the Patient been registered in the NHS before? Yes No If 'no' please state date entered UK DD slash MM slash YYYY * 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. If you do not consent to being contacted by SMS or Email, please tick here: SMS Optional Email Optional Other DetailsPrevious GPName of GP Address Street Address Address Line 2 City Postcode Town & Country of Birth EthnicitySelect…White (UK)White (Irish)White (Other)Black CaribbeanBlack AfricanBlack OtherBangladeshiIndianPakistaniChineseOtherReligion OptionalSelect…C of ECatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah’s WitnessNo religionOtherHousing OptionalSelect…Own HouseRented HouseShared HouseNursing HomeResidential HomeSheltered HomeHomelessHouseboundAsylum SeekerRefugeeEmployment OptionalSelect…EmployedSelf-employedStudentUnemployedHouse husbandHouse wifeCarerRetiredOverseas Visitor Yes Optional European Health Insurance Card Held (please bring details with you) Optional Armed Forces Military Veteran Optional Family Member Optional Communication NeedsLanguageWhat is your main spoken language? Do you need an interpreter? Yes No CommunicationDo you have any communication needs? Yes No Please specify below Hearing aid Optional Lip reading Optional Large print Optional Braille Optional British Sign Language Optional Makaton Sign Language Optional Guide dog Optional Optional Learning disabilityDo you have a Learning Disability? Yes No (If yes please request a Learning Disability Screening Tool form) Carer DetailsAre you a carer? Yes – Informal / Unpaid Carer Yes – Occupational / Paid Carer No Do you have a carer? Yes No Your carer's detailsOnly add carer’s details if they give their consent to have these details stored on your medical recordName First Last Telephone Number OptionalRelationship Optional 2. Medical History Medical HistoryHave you suffered from any of the following conditions? Asthma Optional COPD Optional Epilepsy Optional Heart Disease Optional Heart Failure Optional High Blood Pressure Optional Diabetes Optional Kidney Disease Optional Stroke Optional Depression Optional Underactive Thyroid Optional Cancer Optional Asthma: onset date (approx year.) Optional COPD: onset date (approx year.) Optional Epilepsy: onset date (approx year.) Optional Heart Disease: onset date (approx year.) Optional Heart Failure: onset date (approx year.) Optional High Blood Pressure: onset date (approx year.) Optional Diabetes: onset date (approx year.) Optional Kidney Disease: onset date (approx year.) Optional Stroke: onset date (approx year.) Optional Depression: onset date (approx year.) Optional Underactive Thyroid: onset date (approx year.) Optional Cancer: onset date (approx year.) Optional If you checked 'Cancer', please specify which type Optional Any other conditions, operations or hospital admission details Optional If you are currently under the care of a Hospital or Consultant outside our area, please tell us here Optional Family HistoryPlease record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.Family History: Medical problem Asthma Optional COPD Optional Epilepsy Optional Heart Disease Optional Stroke Optional Blood Pressure Optional Diabetes Optional Kidney Disease Optional Depression Optional Underactive Thyroid Optional Cancer Optional Other Optional Family History of Asthma: onset date (approx year.) and which relative Optional Family History of COPD: onset date (approx year.) and which relative Optional Family History of Epilepsy: onset date (approx year.) and which relative Optional Family History of Heart Disease: onset date (approx year.) and which relative Optional Family History of Stroke: onset date (approx year.) and which relative Optional Family History of Blood Pressure: onset date (approx year.) and which relative Optional Family History of Diabetes: onset date (approx year.) and which relative Optional Family History of Kidney Disease: onset date (approx year.) and which relative Optional Family History of Depression: onset date (approx year.) and which relative Optional Family History of Underactive Thyroid: onset date (approx year.) and which relative Optional Family History of Cancer: onset date (approx year.) and which relative Optional If you checked "Other", please specify below Optional AllergiesPlease record any allergies or sensitivities below Optional 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 Optional 3. Your LifestyleAUDIT–C QUESTIONS Please check the correct boxes and check your score. (Scores can be found to the left of your chosen answer)How often do you have a drink containing Alcohol?Select…0: Never1: Monthly or Less2: 2-4 times per month3: 2-3 times per week4: 4+ times per weekHow many units of alcohol do you drink on a typical day when you are drinking?Select…0: Never1: Monthly or Less2: 2-4 times per month3: 2-3 times per week4: 4+ times per weekHow often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?Select…0: Never1: Monthly or Less2: 2-4 times per month3: 2-3 times per week4: 4+ times per weekTotal Score 4 or less 5 or more A score of less than 5 indicates lower risk drinking Scores of 5 or more require the following 7 questions to be completed:AUDIT QUESTIONS (After completing 3 AUDIT-C questions above)How often during the last year have you found that you were not able to stop drinking once you had started?Select…0: No2: Yes, but not in the last year4: Yes, during last yearHow often during the last year have you failed to do what was normally expected from you because of your drinking?Select…0: No2: Yes, but not in the last year4: Yes, during last yearHow often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?Select…0: No2: Yes, but not in the last year4: Yes, during last yearHow often during the last year have you had a feeling of guilt or remorse after drinking?Select…0: No2: Yes, but not in the last year4: Yes, during last yearHow often during the last year have you been unable to remember what happened the night before because you had been drinking?Select…0: No2: Yes, but not in the last year4: Yes, during last yearHave you or somebody else been injured as a result of your drinking?Select…0: No2: Yes, but not in the last year4: Yes, during last yearHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?Select…0: No2: Yes, but not in the last year4: Yes, during last yearTotal Score 3. Your Lifestyle (continued) SmokingDo you Smoke?Select…Never smokedEx-smokerYesDo you use an e-Cigarette?Select…Never smokedEx-smokerYesWould you like help to quit smoking? Yes No For further information, please see:www.nhs.uk/smokefree Height and WeightHeight Weight Waist Circumference Optional Women OnlyDo you use any contraception? Yes Optional No (If needed book an appointment) Optional Are you currently pregnant or think you may be? Yes Optional No Optional Expected due date Optional MM slash DD slash YYYY Students OnlyStudents are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. For further information, please see: www.nhs.uk/Livewell/Studenthealth I am less than 24 years old and have had two doses of the MMR Vaccination Yes Optional No Optional Unsure Optional I am less than 25 years old and have had a Meningitis C Vaccination Yes Optional No Optional Unsure Optional 4. Further Details Named Accountable GPThe GP who has overall responsibility for your care is? Optional You are however entitled to make an appointment to see any GP of your choice, subject to availability. Electronic PrescribingIf you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use Optional Patient Participation GroupWould you like to be involved in our Patient Participation Group? Yes No We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services. Blood and Organ DonationBlood Donation I am already a blood donor I wish to be a blood donor I do not wish to be a blood donor Organ Donation I am already registered as a donor I wish to be a donor – all body parts I wish to be a donor – for these body parts: (please specify below) I do not wish to be a donor specify organs Optional You can register Online -OR- You can call(030 0123 2323) and speak to an advisor who will send out a donor card. SignaturesSignature I confirm that the information I have provided is true to the best of my knowledge.Signature 2 Signed on behalf of patient Name First Last 5. Sharing Your Health RecordYour Health RecordDo you consent to your GP Practice sharing your health record with other organisations who care for you? Yes (Recommended option) No, never Do you consent to your GP Practice viewing your health record from other organisations that care for you? Yes (recommended option) No Your Summary Care Record (SCR)Do you consent to having an Enhanced Summary Care Record with Additional Information? Yes (recommended option) No Signature signature Signed on behalf of patient Name First Last Sharing Your Health Record What is your health record? Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies. Why is sharing important? Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. 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. Below are some examples of how sharing your health record can benefit you: Sharing your contact details (This will ensure you receive any medical appointments without delay) Sharing your medical history (This will ensure emergency services accurately assess you if needed) Sharing your medication list (This will ensure that you receive the most appropriate medication) Sharing your allergies (This will prevent you being given something to which you are allergic) Sharing your test results (This will prevent further unnecessary tests being required) Is my health record secure? Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery. Can I decide who I share my health record with? Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained. Can I change my mind? Yes. You can change your mind at any time about sharing your health record, please just let us know. Can someone else consent on my behalf? If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you. What about parental responsibility? If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision. What is your Summary Care Record? allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future. How is my personal information protected? will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team For further information about your health records, please see: www.nhs.uk/NHSEngland/thenhs/records For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters Access to GP Online Services Important Information – Please read before completing form below If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice. It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password. If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all. During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal. The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text. Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details. Forgotten history There may be something you have forgotten about in your record that you might find upsetting. Abnormal results or bad news If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. Choosing to share your information with someone It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. Coercion If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time. Misunderstood information Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation. Information about someone else If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible. For further information, please see: www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx 6. Online Access To Your Health RecordName First Last NHS Number Optional Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City Postcode PhoneEmail Optional I wish to have online access to: Please tick all that applyonline service list View & book appointments Optional View & request medication Optional Access my coded medical record (contains any medical codes that have been recorded) Optional Access my full medical record (contains medical codes and any free text that has been recorded) Optional Access my Summary Care Record Optional Complete online questionnaires Optional I wish to access my medical record and understand and agree with each statement: Please tick all that applyCheck statements I have read and understood the ‘Important Information’ section below Optional I will be responsible for the security of the information that I see or download Optional If I choose to share my information with anyone else, this is at my own risk Optional I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement Optional If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible Optional Signature Signature 3 Signed by patient Name First Last Email OptionalThis field is for validation purposes and should be left unchanged.