testing (do not use) | Parkbury House Surgery

Registration Checklist for Adults

ID Requirements for Parents/Adults: Passport or drivers licence and proof of address.

Date:

Have you been a patient at Parkbury House Surgery before?

Yes

Your Details

Forename: *

Middle Name/s:

Surname: *

Date of Birth: *

Marital Status:

Name of Care/Residential Home (if applicable):

Address: *

Include Postcode

Mobile Telephone Number:

Home Telephone Number:

Work Telephone Number:

Email Address:

Occupation:

Ethnic Origin:

Sex: *

Male

Female

Transgender

Language and Accessibility

First Language:

Do you need a translator or sign language support?

Yes

Do you have any special communication needs? When we write to you or contact you, do you need up 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 Details

Name:

Relationship:

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?

Yes

Full name of Carer:

Carers Mobile Number:

Carers Home Telephone Number:

Are they registered with our practice?

Yes

The Receptionist will give you information about Carers In Hertfordshire and the support available for you.

Do you care for anyone else?

Yes

Full name of person cared for:

Mobile Number of person cared for:

Home Telephone Number of person cared for:

Are they registered with our practice?

Yes

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

Medical Information

Weight:

Height:

Smoking

Are you a smoker?

Yes

How many do you smoke a day?

1 - 9

10 - 19

20 - 39

39 or more

Are you an ex-smoker?

Yes

When did you quit?

Alcohol Consumption

Please complete the separate Alcohol Consumption Form.

Medical History

Please give details of any significant medical conditions, disabilities, serious past illnesses or operations and the approximate year of diagnosis:

Condition/Operation:

Year:

Condition/Operation:

Year:

Condition/Operation:

Year:

Condition/Operation:

Year:

Condition/Operation:

Year:

Condition/Operation:

Year:

Medication

Are you on regular medication? (name of medication/s and dosage)

If you have a list from your previous GP please give us a copy

Allergies

Are you allergic to any medication, substances or foods?

Yes

Please give details:

Family History

Is there any of the following in your family (father, mother, brother, sister) before the age of 65?

Heart Disease?

Yes

Which family member?

Stroke?

Yes

Which family member?

Cancer?

Yes

Which family member?

Which type of cancer?

Asthma?

Yes

Which family member?

Communication

Parkbury House Surgery uses Text Messaging, Telephone Calls, Post and Email (using the forms of information you have provided) to communicate information regarding your medical care.

Please tick to confirm that you are aware that we communicate in these ways

Parkbury House Surgery uses Text Messaging, Telephone Calls, Post and Email (using the forms of 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 these ways and are happy for us to do so

Parkbury House PPG (Patient Participation Group)

Would you like more information about our PPG?

Yes

Are you interested in joining the PPG?

Yes

Which form of communication would you like to be contacted by?

Telephone Call

Sharing Information

Please see our Privacy Policy.

I confirm that all the information provided on this form is accurate and true.

Date:

Your Details

Language and Accessibility

Next of Kin Details

Carer Details

Medical Information

Smoking

Alcohol Consumption

Medical History

Medication

Allergies

Family History

Communication

Parkbury House PPG (Patient Participation Group)

Sharing Information

Parkbury House Surgery Online