Our Registration & Health Questionnaire Name First Last Date of Birth Day Month Year Occupation/School attended Email Address Enter Email Confirm Email Contact NumberNext of Kin Name First Last Relationship to PatientNext of Kin Contact NumberYou must be given basic access to GP online services, which include: Yourself Parents of children under 12, Proxy access Current health problems?Past health problems?Allergies?Women ages (25 only)Date of last smear test Month Optional Day Optional Year Optional Where was this done? Optional What was the result? Optional Smoking (if aged >14)Are you.. Smoker Ex-smoker Never smoked Your doctors strongly advise all smokers to try and stop. If you are a smoker, would you like help to quit? Yes No AlcoholHow many units of alcohol do you drink in an average week? Optional 1 unit = half pint beer = 1 glass wine (small) = 1 measure spiritsExercise Light Moderate Heavy Are you a carer? Yes No Please give full details.ReligionPlease selectChurch of EnglandHinduPresbyterianRoman CatholicIslamChurch of ScotlandAtheistChristianPentecostalNonconformistSikhNoneJewishBaptistBuddhistChristian ScientistMethodistRastafarianJehovah’s WitnessUnited Reform ChurchPlymouth BrethrenEvangelicalSalvation ArmyMormonEthnic originEthnicityPlease selectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – GreekWhite – KurdishWhite – OtherAsian – IndianAsian – BangladeshiAsian – PakistaniAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed – CaribbeanMixed – AfricanMixed – AsianMixed – OtherChineseFilipinoVietnameseOtherI do not wish to discloseThis questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act. Please choose your ethnic origin. This is not compulsory but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions. – White: White British, White Irish, Other white – Asian: Indian, British Indian, Pakistani/British, Pakistani, Bangladeshi/British Bangladeshi – Mixed: Mixed British, White & Black Caribbean, White & Black African, White & Asian, Other Mixed – Black: Caribbean, African, Black British, Other black – ChineseFirst language: Family Medical History Asthma Optional Heart disease Optional Cancer Optional High Blood Pressure Optional COPD Optional Hypothyroidism Optional Dementia Optional Kidney disease Optional Depression Optional Learning disability Optional Diabetes Optional Mental Health Problems Optional Epilepsy Optional Stroke or TIA (mini stroke) Optional Please state which family member for each medical conditionPills or medicinesIncluding over the counter or alternative treatmentsPlease either list your medicines below or include a copy of your repeat prescription list from your previous surgery OptionalPlease note the name of drug, dose, frequency & the reason you take it for each medicationUpload a copy of your repeat prescription list from your previous surgery OptionalMax. file size: 50 MB.Summary Care RecordSummary Care Records contain key information about the medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had in the past. You will be able to add other information too if you and your GP agree that it is a good idea to do so. If you have an accident or fall ill, the people caring for you in places like accident and emergency departments and GP out of hours services will be better equipped to treat you if they have this information. Your Summary Care Record will be available to authorised healthcare staff whenever and wherever you need treatment in England, and they will ask your permission before they look at it. You need to make a decision.Your GP practice is supporting Summary Care Records and as a patient you have a choice: Yes, I would like a Summary Care Record. If you want a record you do not need to do anything further, one will be created for you when you register with your GP practice. If you opted out of having a record in the past but have now changed your mind, speak to your GP practice and they can create one for you. Yes I would like a Summary Care Record with Additional Information. As well as any allergies or adverse reactions or medications you are taking this also includes: anticipatory care information, significant medical history (past and present), reasons for medications, end of life care information (if any). No, I do not want a Summary Care Record. You are free to change your decision at any time by informing your GP practice. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. SMS Text MessagingSundridge Medical Practice sends text message reminders for your appointments booked with the surgery. I CONSENTto the practice contacting me by text message for the purpose of health information and appointment reminders. I will ensure that I keep the practice informed of my up to date mobile number at all times, or if the number is no longer in my possession I DO NOT CONSENT to the practice contacting me by text message for the purpose of health information and appointment reminders Alcohol ConsumptionHow often do you have a drink containing alcohol? OptionalNever (0)Monthly or less (1)2-4 times per month (2)2-3 times per week (3)4+ times per week (4)How many units of alcohol do you drink on a typical day when you are drinking? Optional1-2 (0)3-4 (1)5-6 (2)7-8 (3)10+ (4)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 OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)Your score: Optional A total of 5 or more indicates increased or higher risk drinking. An overall total of score of 5 or above is AUDIT-C positive. 1. HIV testing to all new Adult Registrations – Do you know your HIV status? – Have you ever had HIV test previously? – When was the last time you were tested for HIV? – In This practice we offer HIV testing to all new adult registrations, do you have an objection to having a test? Speak to your doctor or nurse in your next consultation. – All you need is a blood test with the Nurse or HCA. 2. Hepatitis B and C testing to all new patient registrations from patients in at risk groups and from high risk countries of origin including Asia and China, Africa, South America. 3. Screening and Vaccination for Hepatitis B in at risk groups (born in endemic area and needle sharing) and Hepatitis A and B in MSM [men who have sex with men]. 4. Psychosexual problems – assessment and referrals can be made to existing psychological service (IAPT). Please ask reception for more information and the results will be provided to patients in accordance with national standards and best practice.