New Patient Registration Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number Optional First Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Female Male EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseTown and Country of Birth Address Street Address Address Line 2 City Postcode Mobile Contact Number OptionalHome Contact Number OptionalDo you give consent to us to contact you via text message? Yes No N/A Email Enter Email Optional Confirm Email Optional Please help us trace your previous medical records by providing the following information:Are you moving in to the Selby area Yes No – moving from a local practice, address remains unchanged Your previous address Street Address Address Line 2 City Postcode Previous doctor Address of previous doctor Street Address Address Line 2 City ZIP / Postal Code If you are from abroadYour first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional Supplementary QuestionsAre you ordinarily a resident in the UK? Yes No European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? Yes Optional No Optional Communication NeedsDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language? DisabilityDo you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional A learning difficulty Optional An impairment, health condition or learning difference that is not listed above Optional Blind or have a visual impairment uncorrected by glasses Optional Deaf or hearing impaired Optional Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional No known impairment, health condition or learning difference Optional Prefer not to say Optional Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalArmed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes No Service or personnel number Enlistment date DD slash MM slash YYYY Discharge date DD slash MM slash YYYY Address before enlisting Street Address Address Line 2 City ZIP / Postal Code Immigration statusIf applicable, what is your current immigration status? Asylum Seeker Optional Failed Asylum Seeker Optional CarersAre you a carer? Yes No Are you a formal or informal carer? Formal – employed carer Informal – caring for relative or friend Is the person you care for registered at Posterngate Surgery Yes No If an informal carer, details of the person you care for First Last Date of birth DD slash MM slash YYYY Do you have a carer? Yes No Carers name First Last Carers phone numberEmergency ContactFull Name Relationship to you Contact NumberDo they live at the same address? Yes No Address Street Address Address Line 2 City Postcode Are they your next of kin? Yes No Do you give us permission to discuss your medical records with them? Yes No About YouHeight Weight Smoking Status Current Smoker Ex Smoker Never Smoked What do you smoke? e.g. Cigarettes, Vape, CigarsHow many do you smoke per day? Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per week OptionalAlcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How often do you have a drink containing alcohol? Never Monthly 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? Never Less than monthly Monthly Weekly Daily or almost daily Medical HistoryMajor Illnesses and Conditions OptionalPlease include datesFamily History Illnesses OptionalPlease include datesCurrent Medication OptionalPrescriptions are sent electronically to your nominated pharmacy, please enter your nominated pharmacy Sight Good Poor Registered Blind Hearing Good Poor Partially Deaf Deaf Are you over 75 years old?The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.AllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include datesImportant Registration InformationSummary Care RecordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? Yes No Do you consent to standard or enhanced Summary Care Record? Express consent for medication, allergies and adverse reactions only (standard) Express consent for medication, allergies, adverse reactions and additional information (enhanced) Your Medical Information – Sharing Your DataPlease see the privacy notice on our website for more information on hour your data is held and used by the practice.I wish to share my Posterngate Surgery medical record with other NHS organisations (sharing out) Yes No (e.g. health visitors, district nurses, podiatry)I wish to share my NHS medical record with Posterngate Surgery (sharing in) Yes No (e.g. health visitors, district nurse, podiatry)I permit my medical record to be shared outside of the GP practice for research and planning purposes (tier 1 opt out) Yes No NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323What happens to my information?Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year Untitled First Choice Optional Second Choice Optional Third Choice Optional Date Optional MM slash DD slash YYYY Untitled First Choice Optional Second Choice Optional Third Choice Optional