New Patient Questionnaire

New Patient Registration Questionnaire

Welcome to Victoria Park Medical Centre. Please could we ask you to complete this important health questionnaire with as much information as possible, as it may take a while for your medical records to be transferred from your previous surgery.

We now ask all patients registering with us to provide two forms of ID – ideally one with a photograph (e.g. passport or driving licence) and one with an address (e.g. utility bill or letter from bank).

We offer all our new patients a health check when we have received their records. If you would like one please make an appointment with one of our Health Care Assistants and bring a urine sample to the appointment.

Personal Details

Title
Address
Address
Postcode
City
Country
Residential Status

Collecting Information About Your Ethnic Group

Please would you be kind enough to indicate below which Ethnic Group best describes you.
We need this information to comply with the law as the Race Relations (Amendment) Act 2000 gives Public Authorities, such as NHS providers, a duty to promote race equality and good race relations. In addition, it has been decided that knowing your ethnicity is medically beneficial to your health.

White
Mixed
Asian or Asian British
Black or British Black
Chinese or other ethnic group
First Language

Next of Kin (In case of Emergency)

Address
Address
Postcode
City
Country

Caring

Do you have an external Carer?
Are you a Carer?
Would you like a Carer’s Support Worker to contact you?

Consent Preferences

Can we contact you via the following? Please tick if yes, if no leave blank.
Do you give consent share to share your patient data with a specified 3rd party?
Smoking Status (please tick)

Blood Pressure

(Please use machine in waiting room)

Alcohol Consumption

Exercise Status

(please tick)

Medical History

Do you suffer from any of the following Conditions? (please tick)
Do you have any disabilities?

Family Medical History

(i.e. parents, brothers and sisters)

Please indicate whether a family member has suffered from any of the following. If the answer is yes, please specify which family member.

Condition
Family Member

Allergies

Do you have any allergies?

Current Medication

Do you take any regular medication? (If yes please list below)

Repeater

Data Protection

By registering at this practice you give your consent for your records to be accessed by those providing your care. For more information please see the leaflet ‘How we use your Health Records’, available in Reception

Summary Care Record – your emergency care summary

Victoria Park 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 will be asked if healthcare staff can look at your Summary Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. You can refuse if you think access is unnecessary.

You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you are happy for a Summary Care Record to be set up for you then you need take no further action. If you want to opt-out now please ask for a ‘Summary Care Record Opt-Out’ form

Children under the age of 16

Patients under 16 years will not receive this information, but will have a Summary Care Record created for them unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please either make this information available to them, or decide and act on their behalf. Ask the surgery for additional forms if you want to opt them out.