Booklet which will provide you with all important information about our practice.

Transcription

1 HARBOUR VIEW HEALTHCARE Shoreham Health Centre, Pond Road Shoreham-by-Sea, West Sussex.BN43 5US Telephone / Downsway Southwick, West Sussex. BN42 4WA Telephone Welcome to Harbour View Healthcare We want to make your transition to our Practice as easy as possible so would ask that you take a couple of minutes to look over and complete the necessary documentation for us to do this. We have provided a registration pack for you, which include the following: Booklet which will provide you with all important information about our practice. Registration form (please note a form will have to be completed for every member of the family that wants to be registered with us). Patient Health Questionnaire, which helps the Doctors and Nurses to assess your particular needs. Information on and text messaging services. Summary Care Record, please can you take your time to tick your choice. If you wish to opt out of the summary care record then please ask reception for an opt out form. Electronic Prescription Service patient nomination PROOF OF ID We need some Proof Identity and Proof of Residency. Documents that could be used to provide identification are listed below. If identification is not provided, regretfully we will not be able to register you as a Patient at our Practice. Proof of Identity Birth Certificate Marriage Certificate Medical Card Driving Licence Passport Proof of Residency Local Authority/Landlord Tenancy Agreement Utility Bill Wage Slip Evidence of Benefit Entitlement Letter from Employer or Further Education Please complete this form and return it to us as soon as possible. If you would like to register for online services via Patient Access please ask for a form at Reception. The online services include Appointments, Repeat Medication, Allergies and Test Requests. You will need to bring photo ID in with you. Thank you for choosing to register with Harbour View Healthcare and we trust that you have a long and happy association with us.

2 PATIENT HEALTH QUESTIONNAIRE In order to help us maintain our records and provide a better service to you, we would be grateful if you could spend a few minutes completing this questionnaire. PLEASE ANSWER ALL QUESTIONS. NAME ADDRESS DATE OF BIRTH MARITAL STATUS HOME PHONE MOBILE PHONE NATIONALITY FIRST LANGUAGE INTERPRETER REQUIRED (If English is not first language) YES / NO PREVIOUS MEDICAL HISTORY/ILLNESSES and OPERATIONS ALLERGIES? REGULAR MEDICATION: If you are regularly taking medication or have a current medical condition, we would ask you to make an appointment with one of the GP Partners. Please bring a specimen of urine with you. If you are not taking any regular medication or you do not currently have a medical condition, there is no need for you to book an appointment. IF YOU ARE OVER 40 YEARS OLD, PLEASE WOULD YOU MEASURE YOUR BLOOD PRESSURE ON THE MACHINE IN THE WAITING ROOM AND RECORD IT HERE (or hand the slip of paper to the receptionist, and she can record it) Blood Pressure 1 st Number 2 nd Number IF YOUR BLOOD PRESSURE IS MORE THAN 150/90 PLEASE MAKE AN APPOINTMENT TO HAVE IT CHECKED BY A HEALTH CARE ASSISTANT SMOKING Please answer the following questions if you are over 14 years old Have you ever smoked tobacco Cigarettes? regularly? No per day? (Don t count rare occasions long ago) Do you still smoke? Are you an ex-smoker? Cigars? No per day? When did you give up smoking? If you are still smoking, which do you smoke: - If you are still smoking are you interested in giving up (please tick) If you are interested in giving up, ask the receptionists to make you an appointment with our smoking adviser for help to stop smoking 2

3 ALCOHOL CONSUMPTION (Please Circle) How often do you have a drink that contains alcohol? How many standard alcoholic drinks do you have on a typical day when you are drinking? How often do you have 6 or more standard drinks on one occasion? TOTAL Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week Never Less than monthly Monthly Weekly Daily or almost daily Do you take exercise? (please tick as appropriate) No exercise Light exercise Moderate exercise Vigorous exercise What is your height? What is your weight? What is your occupation? Last cervical smear, date (if applicable) Where possible, please provide the following family history medical details: - Has a member of the family suffered from: - Heart Attack / Angina / Heart Failure Stroke Which family member(s)? Approx age of onset of the condition (if known) Hypertension (High Blood Pressure) Diabetes Asthma Cancer (State type of Cancer?) Other (please state) 3

4 OPTIONAL ADDITIONAL INFORMATION: - Please could you give us the following information (where relevant) Are you a carer? Do you have a carer? If you answered yes to either of these questions, please ask for a carer s form. Next of kin Name This contact is for emergencies only. Relationship Phone no Name of Friend / Neighbour (who would be a useful contact in an emergency) To give consent to another person to have information of your appointments or medical records please ask for a Permission to Disclose Data form. Phone number of Friend or Neighbour Key Safe Code No (for flats for the elderly etc) Some medical conditions are more commonly found in certain ethnic groups. In order to help us meet every patient s health needs we could be grateful if you could circle which ethnic group you feel you belong to: BRITISH OR MIXED BRITISH AFRICAN BANGLADESHI OR BRITISH BANGLADESHI CARIBBEAN CHINESE INDIAN OR BRITISH INDIAN IRISH PAKISTANI OR BRITISH PAKISTANI WHITE AND ASIAN WHITE AND AFRICIAN OTHER WHITE BACKGROUND OTHER PLEASE STATE: Thank you for your cooperation in completing this questionnaire. The data will be transferred onto your computer medical record. No person outside the practice has access to the computer. Only anonymous statistics (without names and addresses) will form part of practice reports. 4

5 , PHONE CONTACT & TEXT MESSAGING SERVICES addresses We are looking to extend the use of addresses and text messaging services for our patients. Please would you indicate, by completing the below if you are happy for us to contact you by , bearing in mind that this may contain confidential information about yourself. Please also be aware that the integrity and security of s cannot be guaranteed on the internet and if you are asking us to use an address at your place of work that this may be seen by other colleagues and in the case of nondelivery be forwarded to a general postmaster. I (Full name) (date of birth) Confirm that I am happy for Harbour View Healthcare to contact me by the following address and I understand that the content of the s may contain confidential information. address Signed Date Telephone Contact Please indicate if you are happy for us to leave messages on your contact numbers: YES/NO (please circle) I(full name) (date of birth) Confirm that I am happy for Harbour View Healthcare to leave messages on my contact phone numbers. Text message services We are looking at extending our text messaging services. We will shortly be setting up a service where we can send a reminder to your mobile phone about your appointments. We will also like to use this service to remind you about any information that maybe missing from your medical record. This could be just that you need a recent blood pressure taken. I(full name) (date of birth) Confirm that I am happy to receive text message reminders about appointments and any health reminders from Harbour View Healthcare. Mobile phone number You will also need to remember to inform us of any changes to your address or mobile number. 5

6 SUMMARY CARE RECORD PLEASE READ THIS BEFORE SAYING YOU WANT TO OPT OUT OF THE SUMMARY CARE RECORD. AFTER READING THIS SECTION IF YOU FEEL YOU WOULD LIKE TO OPT OUT OF A SUMMARY CARE RECORD PLEASE ASK RECEPTION FOR A FORM TO OPT OUT. WHAT IS THE SUMMARY CARE RECORD? At the moment as an NHS patient your demographic details (name, address, date of birth, telephone number and Registered GP) are all held on the central NHS database The only way you can opt to not have this information centrally held is to opt out of the NHS altogether by registering with a private practice as a private patient We do not have private patients at this practice. The Government plans to make Summary Care Records available nationally to other doctors or nurses in hospitals or out of hours centres throughout the country so that the most important medical information about you is available to them. For example any allergies you may have or what medication you are taking. This information would not be able to be viewed by just anybody, they would need to be an authorised doctor or nurse. They would need your permission before they could access your record. A Summary Care Record (SCR) is an electronic record of important information about a patient s health. It will initially have information about current medications, allergies and any bad reactions to medicines. Additional information may be added over time if a patient gives their consent. Historically, there has been little or no information available to clinical staff when patients are seen out of hours or in an emergency. The Summary Care Records will be available to authorised healthcare staff providing patient care anywhere in England, provided the patient gives permission. This means that if a patient has an accident or became ill, healthcare staff treating them will have immediate access to important information about their health. Patients have a choice to make please tick relevant box Yes I would like a Summary Care Record If you would like a Summary Care Record you don t need to take any action as a Summary Care Record would be created for you automatically. No I do not want a Summary Care Record Patients who do not want to have a Summary Care Record should ask reception for a form to complete to opt out. You can phone the Summary Care Record Information Line on or visit the website at for further information. Alternatively contact the Patient Advice and Liaison Service (PALS) at the PCT on PLEASE DO NOT OPT OUT OF THE SUMMARY CARE RECORD UNLESS YOU HAVE READ THIS LEAFLET AND ARE CERTAIN ABOUT THE IMPLICATIONS 6

7 Electronic Prescription Service Patient Nomination Request Patient name Address Telephone Number... DOB... NHS Number I am the patient named above/carer of the patient named above. Nomination has been explained to me and I have also been offered a leaflet that explains nomination. Name and address of nominated dispenser: Patient Signature Date.. 7

8 Official Use only, check list by Receptionist. Please write your name and tick all boxes OFFICIAL USE ONLY Receptionist Name Not Registered here before All Name & Address details completed Previous GP, Previous Post code ID 1 ID 2 Medical Info Height and Weight On Medication or have current medical condition Make appointment with GP BP If over 150/90 make appointment with Health Care Assistant DATE: TIME: DATE: TIME: Smoking Alcohol Family history Code added for communication by Code added for communication by Text Code added for Named accountable GP (9NN60) EPS nomination updated on emis Summary Care Record Opt Out Form 8