ALTON SURGERY
HURSTONS LANE, ALTON, ST10 4AP
Phone: 01538704200 Email: altonsurgery@nhs.net

New Patient Registration

About you

Surname: ……………………………………   Forename(s): …….…………………………………

Date of Birth (dd/mm/yyyy): ……………….   NHS number (if known): ………………………….

Gender: ……………………………………      (www.nhs.uk/find-nhs-number)

Contact Information

Address: ………………………………………………………………………………………………….

Telephone: ………………………………………  Mobile: ……………………………………………

Email: ………………………………………………

Please circle below your preferred choice of contact:

Text      Phone      Email        Post    

Residential Status

Do you live in independent housing?				Yes   		No
Do you live alone?					Yes   		No	
Do you live in a residential home?	Yes   		No	

Other…………………………………………………………………………………………………….

Residency

Previous address in the UK (if applicable):………………………………………………………….

Occupation

Current occupation……………………………………………………………………………

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients’ connections to the Armed Forces. Please tick the below boxes that apply to you:

I AM a Military Veteran		I AM currently serving in the Reserve Forces		
I AM married/civil partnership to a serving member of the Regular/Reserve Armed Forces		I AM married/civil partnership to a Military Veteran 		
I AM under 18 and my parent(s) are serving member(s) of the armed forces.		I AM under 18 and my parent(s) are veteran(s) of the armed forces.		

Asylum Seekers

Are you classed as an Asylum Seeker?			Yes 		No 

If so, please indicate your country of origin: ……………………………….

Ethnicity

Having information about patients’ ethnic groups would be helpful for the NHS so that it can plan and provide culturally appropriate and better services to meet patients’ needs.
If you do not wish to provide this information you do not have to do so.

Please indicate your ethnic origin by circling below:

Asian or Asian British	
•	Indian
•	Pakistani
•	Bangladeshi
•	Chinese
•	Any other Asian background
Mixed or multiple ethnic groups
•	White and Black Caribbean
•	White and Black African
•	White and Asian
•	Any other Mixed or multiple ethnic background

Black, Black British, Caribbean, or African
•	Caribbean
•	African
•	Any other Black, Black British, or Caribbean background
White
•	English, Welsh, Scottish, Northern Irish, or British
•	Irish
•	Gypsy or Irish Traveller
•	Any other White background

Any other ethnicity as not indicated above …………………………………….

Preferred title

How would you like us to refer to you (eg Mr, Mrs, Miss, Mx)?...........................................................

Preferred title for official correspondence?...........................................................

Religious affiliation

Do you have a religious affiliation (please give details if so)?...........................................................

Country of birth

In which country were you born?...........................................................

Main language

Which is your main language?.................................................................
Preferred written language? ...................................................................
Do you speak English?	Yes		No
Do you need an interpreter? 								Yes		No 
If so, which language? …………………………………….........................
Carer status

Are you yourself a carer? 								Yes   		No	
Do you have a carer? 								Yes   		No	

If yes, please give details of their name, relationship and whether they are a patient here too………………………………………………………………………………………………………........
Do you give consent for us to contact your carer about your care?			Yes		No 

Next of kin & Emergency contact Information 

Surname: ……………………………………   Forename(s): …………………………………………

Gender: ……………………………………   Relationship to you ……………………………………

Telephone: ………………………………………  Mobile: ……………………………………………

Relationship status

What is your current relationship status?
Please indicate by ticking the below box

Single Person		Civil Partner		
Married		Divorced		
Widowed		Civil partnership dissolved		

Contacting you

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care.

Do you consent to the Surgery sending text messages to your mobile? 	Yes   		No
Do you consent to the Surgery sending messages to you by email?  	Yes   		No
Do you consent to the Surgery sending letters to your home address?  	Yes   		No
(We will not leave detailed messages on your phone but may ask you to contact us or leave a simple message if we do not need to speak to you).	

Preferred method of contact?	…………………………………………………………………………………..

Summary Care Record (SCR)

If you decide to have a SCR, it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had it will also include basic information about your current diagnoses. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly. 

For more information:   visit https://digital.nhs.uk/services/summary-care-records-scr

Please select one of the following options

a)	Express consent for medication, allergies, and adverse reactions only. You wish to share information about medication, allergies, and adverse reactions only. 

b)	Express consent for medication, allergies, adverse reactions, and additional information. You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you. 

c)	Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care. 

Local Shared Electronic Health Record

Many areas of the country have a local shared electronic health record too. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Are you happy for your record to be shared across organisations caring for you? (This is accessed by relevant staff for your direct care on a need-to-know basis only.)

Are you happy to be part of the local shared electronic health care record?
(If you select no, you need to be aware that NHS Healthcare staff may
not be able to see important elements of your care history.				Yes		No

Research and planning

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research. 
If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.  
NHS Digital and other health and care organisations may also share your data with other organisations for research and planning. To opt-out of this data share you will need to head online to register for the National Data Opt-out.
More information about the different data Opt-outs is here: Opt out of sharing your health records - NHS (www.nhs.uk)
Choosing to opt out will not affect your care or treatment.
You can change your choice at any time. Please ask at reception for more information.

Donation wishes

If you live in England, Wales, or Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent.
If you do not want to donate your organs, then you should register your decision to refuse to donate. Remember to speak to your family and loved ones about your decision. To opt out, visit: https://ardens.live/Organ-donation-opt-out

Do you have a donor card or are you on the organ donation register?	Yes   		No	
Have you opted out? 								Yes   		No	
Do you donate blood?								Yes   		No

Resuscitation wishes and Power of Attorney

Does anybody hold any of the following Power of Attorney for you?  
Please indicate by ticking the below box

Lasting power of attorney personal welfare		Enduring power of attorney		
Lasting power of attorney property and affairs		
Lasting power of attorney personal welfare with authority for life sustaining decisions		

Name of attorney…………………………...   Contact number……………………………………….

Where is the Power of Attorney held ………………………………………………………………….

Do you have a DNACPR (Do not attempt CPR) form in place? 		  Yes   		No

If YES, please supply details of who holds this and where (and supply a copy for your medical notes).

Details…………………………………………………………………………………………………………………….

Smoking status 

Do you smoke? 									Yes   		No	
If yes, how many cigarettes do you smoke daily: ……………………………….
If no, have you smoked in the past? 							Yes   		No	
Do you use electronic cigarettes/vape?						Yes 		No

Smoking is the UK’s single greatest cause of preventable illness.
Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription.

If you would like help and advice on how to give up smoking, please contact https://www.nhs.uk/live-well/quit-smoking/ or ask at reception. 

Alcohol intake

How much alcohol do you drink in a week?...............................................................................................

If you would like help and advice on how to reduce your alcohol intake, please contact https://www.drinkaware.co.uk/ or ask at reception.

Exercise Status

How would you describe your exercise status?
Please indicate by ticking the below box

Exercise physically impossible		Avoid even trivial exercise		
Enjoy light exercise		Enjoy moderate exercise		
Enjoy heavy exercise		Competitive athlete		

Height/Weight

What is your height in centimetres: …………………………….

What is your weight in kilograms: ………………………... 

If you would like advice on managing a healthy weight, please contact https://www.nhs.uk/live-well/  or reception who will be able to direct you to the most appropriate service.
Disabilities / Accessible Information Standards_

As a practice we want to make sure that we give you information that is clear to you. For that reason, we would like to know if you have any communication needs. 

Do you have any special communication needs?                                                          Yes	No	

If yes, please state your needs here: …………………………………………………………………………………

Do you have any of the following conditions?
Please indicate by ticking the below box

Registered blind		Registered partially sighted		
Hearing difficulty		Deafness		
Dependence on wheelchair		Speech problem		

Do you have significant mobility issues?					Yes   		No

If yes, are you housebound? 							Yes		No
(Definition of housebound - A patient is unable to leave their home due to physical or psychological illness)

If you have any other disability, please detail below:

………………………………………………………………………………..

Family History and past medical history

Have any close relatives (parent, sibling, or child only) ever suffered from any of the following?

Condition	Yes	No	Relationship to you	Age at diagnosis	
Heart Disease (Heart attack/Angina)					
Asthma					
Hypertension					
Diabetes					
Stroke					
Rheumatoid arthritis					
Cancer					
Epilepsy					

Have you yourself ever suffered from any important medical illness, operation, or admission to hospital? If so, please enter details below:

Condition	Year diagnosed	Ongoing?	

			

Medications

Please provide a list of repeat medications:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Allergies

Please list any drug or food allergies that you have:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

For female patients only

Have you had a cervical smear test? 						Yes   		No	

If yes, when was this last done? (dd/mm/yy) ……………………………………

Are you currently pregnant?								Yes   		No	

If yes, please ensure you are under the care of a midwife. If you’re not currently under the care of a midwife, please speak to reception regarding this. 

Which method of contraception (if any) are you using at present?

……………………………………………………………………………………

Do you currently have long-acting reversible contraception in place? (Implant/Coil)

Yes   	No	

If yes, when was this fitted? (dd/mm/yy)

…………………………………