New Patient Registration Form (GMS1 & Health Questionnaire)

New Patient Registration Form (GSM1 + Health Q's)

If you are new to the area and wish to register with the Practice please complete the form below - each person registering will need to complete a form.

Personal Details
Title(Required)

Mr

Mrs

Miss

Ms

Mx

Dr

Other
NHS Number
First Names(Required)
Surname(Required)
Previous Surname
Date of Birth(Required)

Day
Month
Year
Gender(Required)

Female

Male
Ethnicity(Required)
First Spoken Language(Required)
Town and Country of Birth(Required)
Address(Required)
Street Address Address Line 2 City Postcode
Main Contact Number(Required)
Home Contact Number
Email
Enter Email Confirm Email
Please help us trace your previous medical records by providing the following information:
Your previous address in the UK
Street Address Address Line 2 City Postcode
Name of doctor while at that address
Address of previous doctor
Street Address Address Line 2 City ZIP / Postal Code
If you are from abroad
Your first UK address where registered with a GP
Street Address Address Line 2 City Postcode
If previously resident in UK, date of leaving

Day
Month
Year
Date you first came to live in the UK

Day
Month
Year
Supplementary Questions
Are you ordinarily a resident in the UK?(Required)

Yes

No
European Economic Area (EEA) Country
For a list of EEA countries visit: www.gov.uk/eu-eea
Do 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

No
Demographics
Marital Status(Required)

Single, never married

Married

Civil Partnership

Divorced

Widowed

Separated
Which of the following options best describes you?(Required)

Heterosexual or Straight

Gay or Lesbian

Bisexual

Prefer not to say

In another way
Sex and gender identity - Which one of the following best describes how you think of yourself?(Required)

Male (including trans men)

Female (including trans women)

Non-binary

Prefer not to say

In another way
Is your gender identity the same as the gender you were given at birth?(Required)

Yes

No

Prefer not to say
Please specify the ethnic group you consider you belong to(Required)

English

Welsh

Scottish

Northern Irish

British

Irish

Gypsy or Irish

Traveller

Any other White background

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed / Multiple ethnic background

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

African

Caribbean

Any other Black / African / Caribbean background

Arab

Any other ethnic group

Prefer not to say
What is your main religion?

No religion

Christian (including Church of England, Catholic, Protestant, and all other Christian denominations)

Buddhist

Hindu

Jewish

Muslim

Sikh

Other religion
Communication Needs
Do you speak English?(Required)

Yes

No
Do you read English?(Required)

Yes

No
Are you a British Sign Language user?(Required)

Yes

No
What is your main spoken language?(Required)
Disability
Do 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)
No known impairment, health condition or learning difference
A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy
A mental health impairment, such as depression, schizophrenia or anxiety disorder
A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
A learning difficulty
Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D
Deaf or hearing impaired
Blind or have a visual impairment uncorrected by glasses
An impairment, health condition or learning difference that is not listed above
Prefer not to say
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)
Armed Forces
Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?(Required)

Yes

No
Do you have access to secure housing?(Required)

Yes

No
What is your current immigration status?

Asylum Seeker

Failed Asylum Seeker
Carers
Do you have caring responsibilities?(Required)

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say
Do you have a carer?(Required)

Yes

No
Emergency Contact
Full Name(Required)
Relationship to you(Required)
Contact Number(Required)
Are they your next of kin?(Required)

Yes

No
Do you give us permission to discuss your medical records with them?(Required)

Yes

No
About You
Height(Required)
Weight(Required)
Smoking Status(Required)

Current Smoker

Ex Smoker

Never Smoked
What do you smoke?(Required)

e.g. Cigarettes, Vape, Cigars
How many do you smoke per day?(Required)
Are you interested in advice on how to quit?(Required)

Yes

No
Please state how much exercise and what type of exercise you do per week
Alcohol Consumption
This 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?(Required)

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?(Required)

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?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
Do you have any significant family history we should be aware of?
Medical History
Major Illnesses
Please include dates
Past Operations
Please include dates
Family History Illnesses
Please include dates
Current Medication
We routinely offer HIV screening would you be interested in being screened?(Required)

Yes

No
Sight(Required)

Good

Poor

Registered Blind
Hearing(Required)

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.
Allergies
Do you have any allergies?(Required)

Yes

No
Please specify what you are allergic to, what happens and when you had your first reaction(Required)
Immunisation History
Please list any immunisations/vaccinations you have had
Please include dates
Important Registration Information
For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service
Summary Care Record
This 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?(Required)

Yes

No
Your Medical Information - Sharing Your Data
Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.
NHS Organ Donor registration
For more information on organ donation please visit:
NHS Blood Donor registration
If 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 03001232323
What 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.
Signature
Declaration
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
Signature(Required)

Your Full Name
Date(Required)

Day
Month
Year

New Patient Registration Form (GSM1 + Health Q's)

Personal Details

Please help us trace your previous medical records by providing the following information:

If you are from abroad

Supplementary Questions

European Economic Area (EEA) Country

Demographics

Communication Needs

Disability

Armed Forces

Carers

Emergency Contact

About You

Alcohol Consumption

This is one unit of alcohol:

Each of these is more than one unit:

Medical History

Are you over 75 years old?

Allergies

Immunisation History

Important Registration Information

Summary Care Record

Your Medical Information - Sharing Your Data

NHS Organ Donor registration

NHS Blood Donor registration

What happens to my information?

Signature