New Patient Questionnaire – Adult | Parkbury House Surgery

New Patient Questionnaire - Adult

Have you been a patient at Parkbury House Surgery before?

Yes

Your Details

Forename: *

Middle Name/s:

Surname: *

Marital Status:

Name of Care Home/Residential Home (if applicable):

Address (including postcode): *

Phone Number:

Occupation:

Gender:

Male

Female

Indeterminate

Refugee Status

Are you a Syrian Refugee?

Yes

Language and Accessibility

What is your first language?

If your first language is not English, do you need a translator or sign language support?

Yes

Do you have any special communication needs?

Yes

When we write to you or contact you, do you need us to communicate in a particular way?

Yes

The receptionist will ask you some other questions to enable us to communicate with you effectively.

Next of Kin

Forename:

Surname:

Relationship to patient:

Address (including postcode):

Mobile Number:

Home Telephone Number:

Carer Details

Do you have anyone who looks after you or your daily needs as a Carer (unpaid)? *

Yes

Do you care for anyone else (unpaid)? *

Yes

Carer/Person Cared For Details:

Forename:

Surname:

Phone Number:

Are they registered with our practice?

Yes

The receptionist will give you information about Carers in Hertfordshire and the support available to you.

Veteran

Are you a Veteran of the British Armed Forces? *

Yes

Please bring in details of your medical history from the MoD which includes the Annex A form allowing us to request your full medical documentation. Telling us about your veteran status enables you to benefit from veteran-specific services.

Smoking

What is your smoking status? *

Never smoked

Ex smoker

Smoker

How many do/did you smoke in a day?

Medication

Are you on any regular medication?

Yes

Please provide details, including dosage:

Prescriptions
Parkbury House Surgery send all prescriptions via the Electronic Prescribing Service to your chosen pharmacy. Please identify below the pharmacy you would like to receive your prescriptions. You have the right to collect medicines prescribed for you from any pharmacy of your choosing. For your convenience, please note that Parkbury House has an onsite pharmacy open until 10pm weekdays and late on the weekend.

Name of Nominated Pharmacy:

Allergies

Are you allergic to any medication, substances or foods?

Yes

Please give details:

Communication

Parkbury House Surgery uses Text Messaging, Telephone Calls, Post and Email (using the information you have provided) to communicate news and updates from the practice and our Patient Participation Group. No more than one communication a month - unless there are exceptional circumstances.

Please tick to confirm that you are aware that we communicate in all these ways and are happy for us to do so

Select preferred method of contact

Telephone

Post

Text

Patient Participation Group

Would you like to hear more information about our PPG?

Yes

Are you interested in joining the PPG?

Yes

Which form of communication would you prefer?

Telephone call

Sharing Information

Please read our Privacy Statement to see how we share your information.

Sharing Information through the NHS Digital

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments.

NHS Digital has a legal responsibility to collect data about NHS and social care services.

The NHS can’t analyse all information on its own, so we safely and securely share some with researchers, analysts and organisations who are experts in making sense of complex information. We only share what’s needed for each piece of research, and wherever possible, information is removed so that you can’t be identified.

You can choose not to have information about you shared or used for any purpose beyond providing your own treatment or care.

Managing your data choice :
Unfortunately, the national data opt-out cannot be set by the GP Surgery. From October 2018 you can choose to stop your confidential patient information being used for purposes other than your own care and treatment.
This choice is known as a national data opt-out. If you choose to opt out, go to : www.nhs.uk/your-nhs-data-matters or call 0300 303 5678.

Summary Care Record with Additional Information

The NHS Summary Care Record (SCR) is an electronic summary of key clinical information (including medicines, allergies and adverse reactions) about a patient, sourced from the GP record. It is used by authorised healthcare professionals, with the patient’s consent (if they are concious and able to give their consent), to support their care and treatment. Where a patient and their doctor wish to add additional information to the patient’s Summary Care Record, this may be added with the explicit consent of the patient.

This information could save your life in an emergency where you are unable to communicate.

More than 96% of the population have an SCR and it is already being successfully used in many settings across the NHS, such as A&E departments, hospital pharmacies, NHS 111 and GP out of hours services and walk in centres.

Select ONE of the options below:

I choose to Opt Out of sharing my Summary Care Record

I agree to Express Consent to SCR

I agree to Express Consent to SCR with Additional Information

My Care Record

My Care Record - Where NHS professionals are directly involved in your care locally, you may be asked to give consent for them to view ‘My Care Record’ which gives direct access to your care record at the Surgery. Further information is available on www.mycarerecord.org.uk. This access is limited to local NHS organisations in order that they can make the best decisions about your diagnosis and treatment. They can only view your record and cannot edit or save your information, however they will notify us separately of the care given to you.

I confirm that the information I have provided is true to the best of my knowledge

Full Name: *

Date:

Parkbury House Surgery

New Patient Questionnaire – Adult