New Patient Questionnaire

Please complete all of the sections below accuratley. Failure to do so, may result in your registration not being processed.

Patient Details

Title

Last Name

First Name

Previous Surname(s)

Date of Birth

What is your sex as recorded on your NHS record?

Home Address

Postcode

NHS Number (if known)

Previous Address Details

Are you registering with a UK GP for the first time?

Previous address

Postcode with last UK GP Practice

Date first came to live in UK

Contact Details

Primary Telephone Number

Secondary Telephone Number

Email Address

Contact Preferences

Telephone

Post

Place of birth

Are you returning from overseas?

Country of birth

Place of birth

Ethnicity

What is your ethnic group?

Please state your first language

Interpreter required?

Previous GP Surgery

Name of Surgery

Postcode of Surgery

Town or City

Nominated Pharmacy

Would you like to choose or change a pharmacy for your prescriptions?Choosing or nominating a pharmacy means the GP surgery will send prescriptions directly to the pharmacy.

Name of nominated Pharmacy

Armed Forces

Are you registered with the Defence Medical Services?You may be registered with the Defence Medical Services (DMS) if you or a family member were in the UK armed forces and this is the first time you are registering with an NHS GP since you or they left service.

Emergency Contact Details

Do you have an emergency contact?

What is the name of your emergency contact?

What is their relationship to you

This person is my next of kin

Contact telephone numberBy continuing you are confirming that is ok to contact this person in an emergency.

Health questions

Do you have any existing or pre-existing medical conditions?Conditions include asthma, dementia, diabetes, cancer or heart disease. This will help the GP give the right treatment.

Please provide as many details as possible about your existing conditions

Do you have any allergies?This may include food, drug, and environmental allergies.

Please provide information about your allergies

Do you have any disabilities?It is important to tell us about any disabilities you may have, so your GP can ensure you are given the necessary treatment.

Give a brief description of the condition (optional)

Do you have a carer?

Yes

A carer looks after you because you are not able to look after yourself. This could be because of illness, disability or addiction. Your carer can be an adult or child, family member or friend. They can be paid or unpaid, but may get benefits.

Are you a carer?

Yes

A carer looks after someone who is not able to look after themselves. This could be because of illness, disability or addiction. Carers can be adults or children. They can be paid or unpaid, but may get benefits.

Do you need to be communicated with in an accessible form?

Yes

Tell us about your communication needs (For example, braille, audio, large format or EasyRead.)

Do you currently take any prescription medication?This should include prescriptions for contraception or any medicines from abroad. This will help the GP have these ready for you.

Can you provide more details about your prescription medication?

Lifestyle Questions

What is your height?

What is your weight?

How often do you drink alcohol or have a drink containing alcohol?This includes wine, beer, spirits, Alcopops, cocktails or hot drinks with spirits such as a coffee with whiskey.

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

What is your smoking status?

How many do you smoke / vape a day?This includes roll ups and cigarettes

Opt out of sharing your health records

The NHS uses information about patients (patient data) to research, plan and improve:

the services we offer

the treatment and care patients receive

We get this data from your GP surgery, hospitals and other healthcare providers. The organisation that collects your data is called NHS England.

To help improve services, NHS England shares this data with researchers from organisations such as universities or hospitals. This type of data-sharing has been happening for many years. All data that is collected and shared is protected by strict rules around privacy, confidentiality and security.

Website for information - https://www.nhs.uk/using-the-nhs/about-the-nhs/opt-out-of-sharing-your-health-records/

Opt-out options

Opt-out - I do not allow my identifiable data to be shared outside of the GP practice for purposes expect my own care.

Opt-in - I do allow my identifiable data to be shared outside of the GP practice for purposes expect my own care.

Summary Care Record

The Crown Medical Centre offers its patients the choice of having a Summary Care Record.

The new NHS Summary Care Record has been introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with.

What is the NHS Summary Care Record?

The Summary Care Record contains basic information about:

- any allergies you may have,

- unexpected reactions to medications

- and any prescriptions you have recently received

The intention is to help clinicians in Accident and Emergency Departments and ‘Out of Hours’ health services to give you safe, timely and effective treatment.

Clinicians will only be allowed to access your record if they are authorised to do so and, even then, only if you give your express permission. You can refuse if you think access is unnecessary.

For more information, please visit: https://digital.nhs.uk/services/summary-care-records-scr

Please select one option below:

Yes I want a Summary Care Record

No I do not want a Summary Care Record

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Crown Medical Centre • Venture Way, Taunton, TA2 8QY.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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