NEW PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE Plympton Medical Practice Ivybridge Medical Practice Chaddlewood Medical Practice Wotter Medical Practice The information that we are seeking on this form is to help us offer you the best advice and treatment that we can. Please tell us as much as you can and return this form to the surgery together with the registration form and documents to verify your identity. We can then book an appointment for your new patient check. ABOUT YOU Title Surname Previous Surname Address Date of Birth Forename(s) Occupation Home Phone Post Code Marital Status (circle as appropriate) Details of parent or guardian (if under 18) Married or Civil Partnership WHY WE NEED TO VERIFY YOUR IDENTITY Mobile Phone E-Mail Address Preferred Phone Number Widowed Divorced or Separated Single It is not uncommon for people to use false names to register with practices and then obtain prescription drugs fraudulently. This costs the NHS money and we need to play our part in attempting to combat this fraud. It is now local NHS policy that all individuals seeking to register with practices in Plymouth, either as new patients or temporary residents, should provide proof of identity. This means verifying your name and also where you live or used to live. Acceptable documents for proof of name are: Passport Marriage certificate National insurance number card Driving licence Birth certificate NHS card Local authority rent card Acceptable documents for proof of address are: Council tax payment book or correspondence Bank or credit card statements Utility bills (gas, electricity or land line telephone) When returning your completed registration form and new patient questionnaire please present one document to verify your name and another to verify your address. For practice use only Identification provided Questionnaire responses checked by Y/N Computer No Summary Care Record Opt-out coded (if appropriate) Date of registration Smoking cessation advice given Y/N Read-coded by Y/N Page 1 of 11 WE 06/14

Smoking cessation literature given Y/N First language coded Y/N Scanned Y/N Date of new patient check appt Ethnicity coded Y/N Audit to GP Y/N Page 2 of 11 WE Sept 13

YOUR HEIGHT AND WEIGHT Height (indicate units used e.g. feet & inches or cms Weight (indicate units used e.g. stones & pounds or kgs YOUR MEDICAL HISTORY Do you live with any of the following conditions? (please provide approximate date of diagnosis below) Diabetes Type 1 Diabetes Type 2 Hypertension (high blood pressure) Epilepsy Heart Disease Mental Health COPD/Emphysema Asthma Cancer Deafness/hard of hearing Blindness/partial sight If so, when was your last check-up? Have you had any serious illnesses, accidents or operations? Please list all events with dates Are you allergic to anything? (e.g. aspirin, penicillin, bee stings, sticking plasters) When was your last Blood Pressure Check Tetanus Vaccination Cervical Smear (women only) IMMUNISATION HISTORY Have you had any of the following immunisations? Give dates if known. Diphtheria/Tetanus/Whooping Cough/Polio and Hib Hib/MenC booster Mumps/Measles/Rubella (MMR) HPV Meningitis C Pre-school booster School leavers booster Pneumococcal Other Immunisations YOUR FAMILY HISTORY Have your parents, brothers or sisters had any of the following conditions before the age of 60? Diabetes High Blood Pressure Heart Attack Stroke Asthma Hay Fever Epilepsy or Fits Other Conditions Page 3 of 11 WE 06/14

YOUR ETHNIC GROUP (circle the appropriate group) White British White Irish Other White Background Mixed White and Black Caribbean Mixed White and Black African White and Asian Indian Pakistani Bangladeshi Caribbean African Other Black Background Other Mixed Background Other Asian Background Chinese Other Ethnic Group Declined To Say YOUR FIRST LANGUAGE First Language Consultations are carried out in English. Please indicate if you will need the services of an interpreter Yes / No CURRENT MEDICATION Please supply details of your current medication: (alternatively attach a copy of your current prescription re-order slip) Name of medication Dosage Smoking Do you smoke? Yes/No Have you ever smoked? Yes/No If you are an ex-smoker: When did you stop? (approx month & year) If you are a current smoker: What do you smoke? (delete as appropriate) Cigarettes/cigars/pipe How much did you smoke before giving up? (cigarettes/day or grams tobacco/week) How much do you currently smoke? (cigarettes/day or grams tobacco/week) Page 4 of 11 WE 06/14

CARERS AND THE CARED FOR Caring for a family member, friend or neighbour who cannot manage alone is an important and valuable role that can not only be extremely demanding but also very isolating for the carer, especially as the responsibility can exist around the clock seven days per week. We also know that many people who perform these tasks without support may not see themselves as carers but they are carers nevertheless and it is appropriate that they are offered suitable assistance. Do you look after someone who is ill, frail, disabled or mentally unwell? If so, you are a carer and the practice would like to support you. If you have not previously registered with the practice as a carer, please ask at reception for a Carers Identification and Registration Form. If you are agreeable, we will then pass your details to those organisations which may be able to provide you with appropriate support. As a carer, you are entitled to have your needs assessed by Social Services. A Carer s Assessment will give you the opportunity to talk about your needs as a carer and explore the possible ways that help could be provided. It also looks at the needs of the person you care for. There is no charge for this type of assessment. Are you a Carer? Yes/No (delete as appropriate) What is your relationship to the person you care for: e.g. spouse, partner, son, daughter, employed carer. Name and address of the person you care for Are you willing for your name to be passed to the carers organisations? Yes/No (delete as appropriate) Is the person you care for registered with this practice? Yes/No (delete as appropriate) Signature Does someone care for you? If someone else cares for you, it is important for us to hold this information in your medical record so please let us have your carer s name and contact details. Surname Title Forename(s) Address Home Phone Work Phone Mobile Phone Post Code Email Is your carer registered with this practice? What is the relationship between you and your carer? e.g. spouse, partner, son, daughter, employed carer. Yes/No (delete as appropriate) Page 5 of 11 WE 06/14

Name.. Alcohol How many units of alcohol do you consume in an average week? Alcohol Questions How often do you consume 8 units (men) or 6 units (women) or more of alcohol on a single occasion? How often in the last year have you not been able to remember what happened when drinking the night before? How often in the last year have you failed to do what was expected of you because of drinking? Has a relative, friend, doctor or health worker been concerned about your drinking or advised you to cut down? Scoring System 0 1 2 3 4 No Yes, but not in the last year A total of 3+ indicates hazardous drinking Yes, during the last year TOTAL SCORE Your Score Pint of regular beer/lager/cider (5%) = 2.9 units Single measure (25ml) of spirits = 1 unit Can (440ml) of lager (5%) = 2.2 units Bottle (700ml) of spirits (40%) = 28 units Bottle (275ml) of alcopop (5%) = 1.4 units Glass (125ml) of wine (12%) = 1.5 units Bottle (750ml) of wine (12%) = 9 units If your total score above is 3 or more please complete the questionnaire overleaf Page 6 of 11 WE 06/14

Alcohol Questions Scoring System 0 1 2 3 4 Your Score How often do you have a drink containing alcohol? 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? How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? No Yes, but not in the lest year Yes, during the last year Has a relative, friend, doctor or health worker been concerned about your drinking or advised you to cut down? No Yes, but not in the last year Yes, during the last year Scoring: 0 7 Lower risk, 8 15 Increasing risk, 16 19 Higher risk, 20+ Possible dependence TOTAL SCORE Page 7 of 11 WE 06/14

SUMMARY CARE RECORD The NHS in Plymouth is introducing the new Summary Care Record (SCR). The SCR will contain details of your medication and any allergies or adverse reactions you may have. There is also the potential for additional information to be added at some point in the future but this will require your specific agreement. The SCR will be uploaded from the practice s electronic records system and held securely on an NHS database. It will be particularly useful to staff in hospital emergency departments and those providing out of hours GP cover but access will be limited to people with appropriate permissions and those people should seek your authority each time they wish to access an SCR unless you are medically unable to give it. If you are content for your data to be uploaded and held centrally by the NHS you need do nothing but if you do not want this to happen you must opt out. This means that you must complete the opt out form overleaf and it and return it to your GP surgery as soon as possible. Your record will then be annotated to indicate that you do not give consent for your details to be uploaded. If you are the parent or guardian of children under the age of 16 years you will either have to let them make the decision themselves or decide on their behalf whether to permit the creation of an SCR or to opt out. If the decision is to opt out then an opt out form will have to be submitted for each child concerned. If you require further information on the subject please do not contact the surgery. Instead you may: visit the NHS Care Records Service website at www.nhscarerecords.nhs.uk or telephone the NHS Care Records Service information line on 0300 123 3020 Page 8 of 11 WE 06/14

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CARE DATA HOW INFORMATION ABOUT YOU HELPS THE NHS TO PROVIDE BETTER CARE Introduction Information about you and the care you receive is shared, in a secure system at the Health and Social Care Information Centre, by the NHS to support your treatment and care. It is important that the NHS can use this information to plan and improve services for all patients. They would like to link information from all the different places where you receive care, such as your GP, hospital and community service, to help them provide a full picture. This will allow them to compare the care you received in one area against the care you received in another, so they can see what has worked best. Information such as your postcode and NHS number, but not your name, will be used to link your records in a secure system, so your identity is protected. Information which does not reveal your identity can then be used by others, such as researchers and those planning health services, to make sure they provide the best care possible for everyone. How your information is used and shared is controlled by law and strict rules are in place to protect your privacy. The NHS needs to make sure that you know this is happening and the choices you have. Care data should not be confused with the Summary Care Record. Benefits of sharing information Sharing information can help improve understanding, locally and nationally, of the most important health needs and the quality of the treatment and care provided by local health services. It may also help researchers by supporting studies that identify patterns in diseases, responses to different treatments and potential solutions. Information will also help to: find more effective ways of preventing, treating and managing illnesses; guide local decisions about changes that are needed to respond to the needs of local patients; support public health by anticipating risks of particular diseases and conditions, and help them to take action to prevent problems; improve the public s understanding of the outcomes of care, giving them confidence in health and care services; and guide decisions about how to manage NHS resources fairly so that they can best support the treatment and management of illness for the benefit of patients. What will the NHS do with the information? The NHS will only use the minimum amount of information they need to help improve patient care and the services they provide. The NHS has developed a thorough process that must be followed before any information can be shared. They sometimes release information to approved researchers, if this is allowed under the strict rules in place to protect your privacy. They are very careful with the information and they follow strict rules about how it is stored and used. The NHS will make sure that the way they use information is in line with the law, national guidance and best practice. Reports that they publish will never identify a particular person. Do I have a choice? Yes. You have the right to prevent confidential information about you from being shared or used for any purpose other providing your care, except in special circumstances. If you do not want information that identifies you to be shared outside the practice please complete the opt-out form below. This will be entered in your medical record and prevent your confidential information being used other where necessary by law, (for example, if there is a public health emergency). Page 10 of 11 WE 06/14

You will also be able to restrict the use of information held by other places you receive care, such as hospitals and community services. Once again, please complete the opt-out form below if you want to restrict the use of this information. Your choice will not affect the care you receive. Do I need to do anything? If you are happy for your information to be shared you do not need to do anything. There is no form to fill in and nothing to sign and you can change your mind at any time. If you are not happy for your information to be shared, please complete the opt-out form below and return it to your normal surgery. Where can I get more information? Leaflets in other languages and formats plus a list of frequently asked questions (FAQs) are available from the NHS Care Data website www.nhs.uk/caredata. You can also get further information from the website at www.hscic.gov.uk or speak to staff at the practice. SHARING PATIENT CONFIDENTIAL DATA OPT-OUT 1. I do not wish any confidential medical data relating to me to leave my GP practice. Signed Date Name (block capitals) Date of Birth For admin use only: Code 9Nu0 entered in patient s record (Dissent from secondary use of GP patient identifiable data) Initials 2. I do not wish any confidential data gathered from any health and social care setting to leave the Health and Social Care Information Centre. Signed Date Name (block capitals) Date of Birth For admin use only: Code 9Nu4 entered in patient s record (Dissent from disclosure of personal confidential data by Health and Social Care Information Centre) Initials Page 11 of 11 WE 06/14