Barcellos Family Practice: New Patient Questionnaire - updated March 2024

Welcome to the Barcellos Family Practice. To accurately register you with the surgery, please complete this questionnaire. You must also provide photographic proof of ID (e.g. passport or a UK photo driving license) and proof of residency (e.g. current utility bill, recent bank statement or letter from host family/college) at your first visit.

Please note your registration cannot be accepted until the forms are completed in full, with all requested details and proof of ID and residency. Thank You

Last Updated: 03/04/2024

Patient's Details

Title *

Surname *

Forename (s) including middle name if applicable *

Previous Surname (if applicable)

NHS number *

Date of Birth (DD/MM/YYYY) *

Marital Status *

Gender *

Female

Male

Non binary

Unable to answer

Prefer not to say

Is your gender the same as the sex you were assigned at birth?

Yes

Prefer not to say

Not able to answer

Full Current Postal Address including Post Code *

Key Safe Number (if applicable)

First Line and Post Code of Previous Address *

Contact Details

It is important that we have up to date contact details in case we need to contact you. We will use these details to call, text or email you about health care services. All phone numbers must be registered in the UK.

A home phone number on which we can contact you *

A Mobile Phone Number on which we can contact you *

An email address on which we may contact you *

Your next of Kin *

Their relationship to you *

Your next of kin's contact telephone number *

Which of these is your preferred number on which we may reach you

Mobile phone

Home phone

Consent to receive communications

If any of the details on this form change in the future, please inform us. In accordance with the Data Protection Act, the Practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing the information on this form you are consenting to be contacted about your medical needs.

This requests your consent to begin communication with you by text or email. *

I consent to the practice contacting me by text message or email for the purposes of health promotion, practice news and for appointment reminders

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me.

Text messages are generated using a secure facility, but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure.

I understand I can cancel the text message facility at any time.

Additional Information Required for your Patient Record

Please help us trace your previous medical records and enable us to provide the best possible healthcare to suit your needs by providing the following information

Carer Information

Why do we ask? Carers are at a much higher risk of becoming ill, and it is essential that you look after your own health and accept any treatment that you need. Ultimately, you cannot look after someone else without first looking after yourself. If we know who our patient carers are, we can improve the services we offer.

Are you a carer for someone else? If Yes, please provide details *

Yes

I care for (name)

Their relationship to you

Would you like to be added to the Practice Carer Register?

Yes

Not applicable

Do you have a designated carer? If Yes, please provide details

Yes

Name and contact details of Carer

Your Medical History

Please provide as much information as possible as this will help your GP give you the best care.

Alcohol use disorders identification test consumption

This section consists of the consumption questions from the full alcohol use disorders identification test (AUDIT).

If your audit C score is 5 or more you can complete a full audit C screening test here https://tinyurl.com/y9nu8nh5.

For help about alcohol please call us or visit www.nhs.uk/live-well/alcohol-support

Thank you for completing this section accurately

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Supplementary Health Information

Smoking Status *

I am a smoker

I have never smoked

I am an ex=smoker

I use an e-cigarette

If you are currently or were a smoker, how many cigarettes do/did you smoke a day?

Would you like help and information to stop smoking? *

Yes No

Weight (please state st/lbs or kgs)

Height (please state ft/inches or metres)

Blood Pressure ( if known, please state as two numbers e.g. 120/80 and the date last recorded)

Women's Health

Are you currently, or think you might be pregnant? *

Yes No

Estimated Date of Delivery if pregnant (EDD) - please state as DD/MM/YYYY

Electronic Prescription Service

The practice can send your prescription to your preferred pharmacy electronically. If you have previously nominated a pharmacy in another area and you now wish to change to a local pharmacy, please inform us of your preferred pharmacy.

My nominated pharmacy is

Patient Participation Group

The Barcellos Family Practice Patient Participation Group (PPG) is made up of people from various backgrounds, each bringing something different to the group. Its members are volunteer patients who work with the practice's managers and clinicians to support and promote the best possible health care for all patients.

For more information about the PPG follow this link to our website>>

Would you like to become a member of the PPG? *

Yes No

Organ Donation

With effect from 15 March 2020, organ donation in England moved to an 'opt-out' system. This means that ALL adults in England will be considered to have agreed to be organ donors when they die unless they have recorded a decision not to donate or are in one of the excluded groups.

Your family will still be approached, and your faith, beliefs and culture will continue to be respected.

You still have a choice about whether or not you wish to become a donor.

Please follow this link to the organ donation website for more information>>

Consent and Data Sharing

If any of the details on this form change in the future, please inform us. In accordance with the Data Protection Act, the Practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing the information on this form you are consenting to be contacted about your medical needs. The Barcellos Family Practice uses SystmOne clinical software. This enables us to share your record with any other NHS organisations who are involved in your healthcare.

Data Sharing Consent Choices (Summary Care Record & Dorset Shared Record)

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (e.g. Emergency Departments). Please download and view this information leaflet, which details which part of your record is extracted and how it is used to help other NHS organisations.

If you wish to OPT OUT, please indicate below.

I wish to OPT OUT of sharing my clinical information

Yes

GP Online Services

If you have provided an email address above, you will be automatically registered for online services with the Practice through ‘SystmOnline’ (including prescription requests, booking (select) appointments, amending your demographic details and access to your medical records).

Find out more about GP Online Services on our Dot It Online web page here>>

If you wish to OPT OUT of being registered to use GP Online Services, please indicate below.

I wisht to OPT OUT of being registered to use GP Online Services

Yes

Complete Registration

Signature *

Signature of patient

Signature on behalf of patient

Signed *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the The Barcellos Family Practice website

Barcellos Family Practice: New Patient Questionnaire - updated March 2024

This section consists of the consumption questions from the full alcohol use disorders identification test (AUDIT).

Further Information

Connect With Us