Health A-Z - GP Bespoke

Title

Gender

Phone No.

NHS No. (Put '0' if unknown)

First Name(s)

Family Name

Maiden Name

Previous Name(s)

Country and town of birth

Address Line 1

Address Line 2

City

County

Postcode

Country

Your previous address in the UK (Leave blank if not applicable)

Address Line 1

Address Line 2

City

County

Postcode

Country

Your previous GP address in the UK (Leave blank if not applicable)

Address Line 1

Address Line 2

City

County

Postcode

Name of your last doctor (Leave blank if not applicable)

This section is only applicable if you have come from outside the UK. Choose "No" if you have been a UK resident your entire life.

Have you come from outside the UK?

Date you first came to live in the UK

Most recent date you left the UK

Most recent date of return to the UK

This section is only applicable if you have come from the Armed Forces. Choose "No" if you haven't come from Armed Forces.

Have you come from the Armed Forces?

Your address before enlisting

Address Line 1

Address Line 2

City

County

Postcode

Country

Service or Personnel No.

Enlistment date

Date of leaving

Ethnicity

Do you need a translator?

Please state any religious or cultural needs below

In the event that we cannot contact you in another way, do you give us permission to contact you via text message on your mobile phone, for example to cancel appointments at short notice, to send flu vaccination information etc. Our messages will only be directly related to your personal healthcare.

Yes - I consent to being contacted via text message on my mobile phone

No - I do not want to receive information this way

Prescriptions will be sent to the local pharmacies below, please select one (this can be changed in the future)

How often do you drink alcohol during the week or weekend?

How many standard units do you have on a typical day when you drink?

How often do you have more than 6 standard drinks on one occasion?

Have you ever smoked tobacco?

Do you smoke now?

How much did you use to smoke?

How long did you smoke for? (in months and years)

Would you like help giving up smoking?

Please provide us with the details of your Next of Kin – This is the person we will contact in case of emergency. Please remember that it is your responsibility to keep this information updated.

Their first name

Their surname

Their relationship to you

Their phone No.

Their address

Address Line 1

Address Line 2

City

County

Postcode

Country

Do you have children?

Name of your child	Their date of birth

Women only - Date & result of your last cervical smear

Women only - Name of GP Practice/NHS/Clinic you had the smear

	Check if applicable
Diptheria
Measles
Pneumovax
Smallpox
Polio
Tuberculosis
German Measles
Tetanus
Influenza
Whooping Cough
Typhoid Fever

	Check if applicable
Cancer
Diabetes
Heart Attack
High Blood Pressure
Epilepsy or Fits
Stroke

Condition / illness and date of diagnosis

List any medicines or tablets and the illness they are for

Tell us what medicines/food/animals you know you are allergic to

Do you regularly do exercise? if you do, please list all your daily regular activities, and for how long below

This could be going to the gym, walking a dog, going to spin classes etc...

Please state communication/information needs that you have, relating to a disability, impairment or sensory loss

Are you a carer?

First name of the person you care for

Last name of the person you care for

Their address

Address Line 1

Address Line 2

City

County

Postcode

Country

Their phone No.

Name of their GP

Would you like us to pass your details onto the Carer’s Service?

Would you like us to refer you for a Carer’s Needs Assessment?

Do you have a carer?

Your carers first name

Your carers surname

Your carers phone No.

Your carers address

Address Line 1

Address Line 2

City

County

Postcode

Country

Other NHS Organisations - We may refer you to other NHS Organisations in the future using our clinical system (TPP SystmOne). If they use the same clinical system on their computers as we do, they are able to see your full electronic medical record, unless you do not give permission to sharing.

Do you consent to sharing your record via TPP SystmOne?

Yes

No

If you do not give permission to sharing, a printed summary of your past relevant medical history will always be sent with any referral letter to another organisation.

Summary Care Records (SCR) - Your Summary Care Record consists of a list of your medications, allergies and adverse reactions, which are extracted from your GP record onto a central/national data base, known as the Spine. In time, this may be expanded to include further medical information. The government has decided that patients’ records will be uploaded UNLESS THEY OPT OUT. We do not offer guidance either way but Opt-Out forms are available at https://www.digital.nhs.uk/services/summary -care -records -scr . If you decide to opt out you should complete the form and provide us with a copy, which we will scan into your record and then remove consent to SCR.

Occasionally members of the CCG /other medical bodies need to look at medical records to verify our procedures. All questions are treated confidentially but if you do not want your records used in this way please tick below.

I do not want my records to be used in this way.

Signature of patient

Signature on behalf of patient

Date

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