Adult Registration – Covent Garden

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Adult registration form (GMS1+questionnaire)

Prefix

First Name *

Middle Name

Last Name *

Date of Birth *

Previous Surname

NHS Number (if known) *

I don’t know or don’t have NHS number

What sex were you assigned at birth?MaleFemale

Town and country of birth *

Street Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code *

Country

Phone Number *Text messaging service enables your GP Practice to get in touch with you by sending text messages to your mobile phone (e.g. text appointment reminders). You are able to text back to cancel or rebook your appointments and send responses to questions. IF YOU CHANGE YOUR MOBILE NUMBER, PLEASE LET YOUR GP KNOW AS SOON AS POSSIBLE

If you don’t want to receive text messages from your practice tick hereI don’t want to receive text messages

Work tel. number

Email Address *

If you don’t want to receive emails from your practice tick hereI don’t want to receive emails from your practice

Please indicate your first choice of contact method (s):LetterEmailSMSPhone

Next of Kin:

Relationship to patient:

Next of Kin contact tel. number:

Are you currently registered or have been registered with a GP? *YesNo

Address of current/previous GP practice *

Previous addresses

Please help us trace your previous medical records by providing the following information. These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and charity services.

Your previous address in the UKN/A

Name of previous GP Ppractice while at that address

Address of previous GP practice

Are you from abroad? *YesNo

If yes please provide your first UK address where registered with a GP *

If previously resident in UK, date of leaving:

Date you first came to live in the UK *

Were you ever registered with an Armed Force GP?NoRegularReservistVeteranFamily Member (spouse, Civil Parnter, Service Chiled)Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Address before enlisting?

Service personel number

Enlistment date

Discharge date:

If you need your doctor to dispense medicines and appliances*I don’t need a doctor to dispense medicine and appliancesI live more than 1.6 km (1 mile) in a straight line from the nearest chemistI would have serious difficaulty in getting them from a chemis* Not all doctors are authorised to dispense medicine

What is your ethnic groupPlease choose the boxes that best descripes your ethnic group or background from the options below:

Ethnicity

Other white background

Mixed ethnicity

Other Mixed background

Asian or Asian-British Backgrounds

Other Asian background

Black or Black-British Backgrounds

Any Other Black background

Other ethnic groups

Any Other background

Patient registered forNHS England use only

SUPPLEMENTARY QUESTIONS

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nati onals of countries outside the European Economic Area must also have the status of ‘indefnite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leafet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confrm any details you have provided.

Are you ordinary resident in the UK?Yes

Please tick one of the following boxes: *I understand that I may need to pay for NHS treatment outside of the GP practice.I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requestedI do not know my chargeable status

Complete this section if you live in an EU country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS .

Do you have a non-UK EHIC or PRC?YesNoIf yes, please enter details from your EHIC or PRC below:

Country Code

Name *

Given Names

Date of Birth *

Personal Identifcation Number

Identifcation number of the institution

Identifcation number of the card

Expiry Date

PRC validity period (a) From:

(b) To:

Do you have an S1 formPlease tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country.

Practice Questionnaire for Adults 16 and over

*Complete a separate form for each family member to be registered

Maritial status

Do you have children :YesNo

Do they live with you?YesNo

Please list : Name, Address and GP DetailsChild,s name, address, GP Name & Address, Relationship to child

Please list other relatives of your home who are registered with us:Name, DOB, Relationship

2 Looking after someone

Are you looking after someone?YesNoLet us know if you are looking after someone who is ill, frail, disabled or has mental health and/or emotional support needs, or substance misuse problems.

Is someone looking after you?YesNoLet us know if a family member, friend or neigbour looks after you. If yes, they are your carer. You are welcome to invite your carer to accompany you to visit at the practice.

Carer's name

Relationship to you:

Address of carer:

Carer's phone number

3 Employment

Are you employed?YesNo

Please specify whether:Full timePart timeSelf-employed

If you are unemployed, please indicate which best describes you:RetiredStudentHousewife/Homemaker/House husbandUnemployedOther (please state)

Other employment status

If returning from the Armed Forces please state which below:ArmyRoyal NavyRoyal Airforce

Comments

4

Your religion

What is your main spoken language?

Do you need an interpreter?YesNo

Do you need help with mobility/hearing/speaking? (tick all that apply)Option WheelchairWalking aidHearing aidBritish sign language (BSL)Makaton sign languageLip readingLarge printBrailleOther

Please state

Are you currentlyHomelessA refugeeAn asylum seeker

Are you an 'Assistance Dog' user?Yes

Are you housebound?Yes

Comments:

Diet and exercise

How much exercise do you do?Sedentary (No exercise)Gentle (climbs stairs, walking, gardning)Moderate (cycling, swimming regularly)Vigorous (Attends gym regularly)

What type of diet do you have?HealthyUnhealthyVeganVegetarianModerate

Lifestyle

Have you ever been a smoker?YesNo

Are a smoker and want to STOP?Yes

Alcohol consumption

Alcohol consumption is measured in units, which is explained in the diagram here: https://www.nth.nhs.uk/live-well/alcohol/know-your-units/

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

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?

alcohol score

Your total score for the above 3 questions is above 4, please complete the questions below:

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

total AUDIT ScoreScoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Women only

What is the date of your last Smear test?

Results

Was this at your GP Surgery?YesNo

Please specify who processed your Smear test :NHSPrivateAbroad

Date of last Mammogram (if applicable):

Medical Background

Are there any serious diseases that affect your child, brothers, or sisters? Tick all that apply and state family member:

Diabetes

RadioYes

Who

Asthma

Yes

Who

Thyroid disorder

Yes

Who

Stroke

Yes

Who

COPD

Yes

Who

Heart Attack under age of 60

Yes

Who

Cancer (specify type)

Yes

Type of cancer and who

High Blood pressure

Yes

Who

Any other important family illness (please state)

Yes

Please specify the illness and who

Please state any country (outside UK) that you have visited/lived in for more than 6 months during the past 5 years:

Dates/Year (If known):