Junction Surgery - New Patient Questionnaire

To register at the Junction Surgery we ask that you complete this form along with a 'Family doctor services registration (GMS1)' form.

Once completed we will need to see proof of identification and so ask that you attend one of our surgeries with this.

Your registration will not be completed until we have verified your identity and have received completed forms.

Last Updated: 12/01/2024

Proof of Identity and Address Provided

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

About you

Title

Name *

Date of Birth *

NHS number (this is essential and can be obtained from your previous GP) *

Ethnicity and main spoken language

Since 1 April 2006 the Department of Health has asked that we record the ethnic origin of all newly registered patients. In certain clinical circumstances this information can be of help to doctors in providing you with more appropriate care.

Address and contact details

Address *

Postcode *

Home phone number

Work phone number

Mobile phone number *

Email address

Do you consent to receiving appointment reminders and other information via text message? *

Yes No

Online services allow you to book appointments, order prescriptions, and view records online. Would you like us to send an online services registration form to your email address? *

Yes No

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Previous address and doctor

Your previous address *

Name of previous doctor *

Address of previous doctor *

Your place of birth *

Date of entry into the United Kingdom (if applicable)

Additional information

Do you have any information or communication needs that you want us to know about? *

Yes No

(If yes please give details)

Are you a military veteran? *

Yes No

If yes, do you want this to be recorded on your medical records?

Yes No

Are you an asylum seeker? *

Yes No

If yes, please state what country you are from

Carers

Are you a carer? *

Yes No

(If yes please give details)

Do you have a carer? *

Yes No

If yes please give details

Smoking

Do you smoke? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking? *

Yes No

If 'No', have you ever smoked?

Yes No

If yes, when did you quit smoking?

Other important things to know

Share for You

As of December 2018 all GP records will be available to view, to other health and social care professionals outside the GP surgery directly involved in your care. For more information please visit: hmrshareforyou.nhs.uk

Named GP

At the Junction Surgery, all of our patients have been registered to a named GP partner and they will be the GP with this responsibility. If you do not know who your registered GP is, please feel free to contact the surgery and a receptionist will be happy to inform you. You may continue to request to see any of our GPs for your appointments and so you should see no change in the day to day running of the practice or your care.

Medical Information

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Alcohol AUDIT-C (Part 1)

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? *

Scoring - Please add up your points from the last 3 questions and enter below. If you score 5 or more, please answer the questions in AUDIT-C part 2. *

Alcohol AUDIT-C (Part 2)

How often in 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 of you because of 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, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Scoring - Please total up your points from the last 7 questions and enter them below

Summary Care Record preferences form

Information about Summary Care Records

You can find information about Summary Care Records using the below links:

SCR - Information for patients

NHS Care Records

NHS Care Records Services Information Line on 0300 123 3020

Opting out

If you wish to opt out of having a summary care record, please complete the linked form and send to us.

Summary Care Record Opt Out Form

Please be advised that we will create your Summary Care Record following your registration with this practice unless you express a preference otherwise *

I confirm that I have read the information about the NHS Summary Care Record

Please confirm if you would like for a Summary Care Record to be created *

Signature

Signature *

Date *

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Junction Surgery - New Patient Questionnaire

Share for You

Named GP

Information about Summary Care Records

Opting out

Further Information