Family doctor services registration (GMS1) Patient's details Mr Mrs Miss Ms First names Surname Previous surname/s Date of birth / Day / Month Year NHS Number Gender Male Female Town and country of birth Address Street Address Street Address Line 2 City County Postcode Telephone Number Please help us trace your previous medical records by providing the following information. Address Street Address Street Address Line 2 City County Postcode Name of previous GP practice while at the address Address of previous GP practice If you are from abroad Your first UK address where registered with a GP Street Address Street Address Line 2 City County Postcode If previously resident in UK, date of leaving - Day - Month Year Date Date you first came to live in UK / Month / Day Year Were you ever registered with an Armed Forces GP Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas. UK or overseas Regular Veteran Family Member (Spouse, Civil Partner, Service Child) Address Street Address Street Address Line 2 City County Postcode Service or Personnel number Enlistment date / Day / Month Year Discharge date / Day / Month Year Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services. If you need your doctor to dispense medicines and appliances I live more than 1.6km in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist Signature of Patient Clear Signature on behalf of Patient Clear Date / Day / Month Year Date NHS Organ Donor registration I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas Date / Day / Month Year Signature confirming my consent to join the NHS Organ Donor Register Clear Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.ul or call 0300 123 23 23 to register your decision. NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Tick here if you have given blood in the last 3 years Date / Month / Day Year Date Signature confirming my consent to join the NHS Blood Donor Register Clear Address Street Address Street Address Line 2 City County Postcode NEW PATIENT HEALTH QUESTIONNAIRE Welcome to Washingborough Family Practice. It is in the interest of both yourself and your doctor that you fill this questionaire to the best of your knowledge. Name First Name Last Name Date of birth - Day - Month Year Address Street Address Street Address Line 2 City County Postcode Telephone number Home Tel Mobile Tel Work Tel Email example@example.com Occupation Religion First Language Next of kin name First Name Last Name Ethnic origin Have you ever been in the forces? Yes No From - Day - Month Year To - Day - Month Year Date Rank Service Number National Service Number Are you a carer? Yes No Women Only If any, what contraception do you use? Date - Day - Month Year Have you had a Hysterectomy? Yes No Are you currently pregnant Yes No Family History – Is there any history of the following in your immediate family Heart attack Heart disease Angina Glaucoma Cystic fibrosis Epilepsy Diabetes Depression High blood pressure Bowel Cancer Breast cancer Stroke Other, please specify New Patient Signature Clear Signature Date - Day - Month Year Please tick if you suffer from or have ever had any of the following conditions Asthma High Blood Pressure Angina Bowel Trouble Epilepsy Diabetes Stroke Gynae Problems Glaucoma Heart Trouble Hayfever Thyroid Disease Pneumonia/Bronchitis Bladder/Kidney disease Arthritis/Joint Problems Depression/Anxiety Cataracts Any cancers Do you have any other health problems or health risk that the doctor/Nurse should be aware of? Are you on any repeat medication? If yes then please enclose a copy of your last repeat prescription slip.this will help us in providing a continual supply of medication. Please be aware we are not informed of your medication needs from your previous GP Browse Files Drag and drop files here Choose a file Cancel of Please state any know allergies Reaction Smoking Status I have never smoked I used to smoke but i do not smoke now I do smoke How many cigarettes per day? How often do you have a drink that contains alcohol? Never Monthly or Less 2-4 times per month 2-3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of your drinking?? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have youn eeded an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? No Yes, but not in the last year Yes, during the last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year Are you currently under Hospital Care Yes No Please give details Do you consider yourself to have a disability? Yes No Details of impairment Physical Impairment Sensory Impairment Learning Disability/Difficulty Mental Health Condition Other If other please state SMS Messaging This is to confirm that I give consent for the Surgery to send text messages to my mobile phone. These textswill be to remind me of future appointments and for health matters relating to my treatment.I am aware that if I change my mobile phone number, it is my responsibility to inform the surgery. Signature for SMS messaging conesent Clear Your Nominated Pharmacy We can send your prescriptions electronically to a Pharmacy of your choice, please let us know your preferredPharmacy to enable us to do this. Patient Record Sharing Preferences Consent Form Please make sure you read the enclosed information sheet for patients prior to signing this form. I confirm I have read the patient’s guide entitled “ Your electronic patient record and the sharing of information Yes No Name First Name Last Name Date of birth - Day - Month Year Address Street Address Street Address Line 2 City County Postcode ENHANCED DATA SHARING MODEL (eDSM) – SHARING OUT Sharing out means that any information that we have recorded at our practice (all consultations, results, medication etc.) will be available for other NHS organisations to see if you allow them to. (You will be asked for your consent for this) . This will make all information added at Washingborough Surgery sharable, and we will be unable to keep any of your information confidential to the surgery. You can always change your mind, but if you have chosen to share information with other NHS organisations and then decide against it we cannot retrieve any information already shared. If I choose to make any information from Washingborough Surgery shareable, I understand this means that ALL information recorded at Washingborough Surgery will be available for other NHS services to view. I do/do not wish to make my information from Washingborough Surgery sharable to other healthcare organisations. I do I do not Signature Clear Date of signature - Day - Month Year Date ENHANCED DATA SHARING MODEL (eDSM) – SHARING IN Sharing in means that Washingborough Surgery will be able to see all information added by other healthcare organisations. This will only happen if you have consented to share information out at the other organisations. I do/do not wish to allow Washingborough Surgery to view information added at other healthcare organisations. I do/do not wish to allow Washingborough Surgery to view information added at other healthcare organisations. I do I do not Signature Clear Date of signature - Day - Month Year Preview PDF Submit Should be Empty:
