New Patient Questionnaire - QEMP

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 16/09/2022

GMS1 Form

Patients Details

Title

Surname *

First Names *

Previous Surnames *

Date of Birth *

NHS Number *

Gender *

Country Of Birth

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Preferred Contact *

Mobile

Landline

Letter

SMS

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

YOUR PREVIOUS ADDRESS IN UK *

NAME OF PREVIOUS GP PRACTICE WHILE AT THAT ADDRESS *

ADDRESS OF PREVIOUS GP PRACTICE

If you are from abroad

YOUR FIRST UK ADDRESS WHERE REGISTERED WITH A GP

IF PREVIOUSLY RESIDENT IN UK, DATE OF LEAVING

DATE YOU FIRST CAME TO LIVE IN UK

Were you ever registered with an Armed Forces GP

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 service charities services.

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

Regular

Family Member (Spouse, Civil Partner, Service Child)

Reservist

Veteran

ENLISTMENT DATE

DISCHARGE DATE (IF APPLICABLE)

ADDRESS BEFORE ENLISTING

SERVICE OR PERSONNEL NUMBER

Complete Registration

*Not all doctors are authorised to dispense medicines

IF YOU NEED YOUR DOCTOR TO DISPENSE MEDICINES AND APPLIANCES*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

SIGNATURE *

Signature of patient

Signature on behalf of patient

SIGNED *

DATE *

What is your Etnic Group

Please tick one box that best describes your ethnic group or background from the options below:

NHS England Use Only

Patient Registered For

GMS

Dispensing

To Be Completed by the GP Practice

Practice Name

Practice Code

I have accepted the patient for general medical services on behalf of the practice

I will dispense medicines/appliances to this patient subject to NHS England approval

I declare to the best of my belief this information is correct (Authorised Signature)

Name

Date

SUPPLEMENTARY QUESTIONS | 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, nationals of countries outside the European Economic Area must also have the status of 'indefinite 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 leaflet, 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 confirm any details you have provided.

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 requested

I do not know my chargeable status

I DECLARE THAT THE INFORMATION I GIVE ON THIS FORM IS CORRECT AND COMPLETE. I UNDERSTAND THAT IF IT IS NOT CORRECT, APPROPRIATE ACTION MAY BE TAKEN AGAINST ME.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

NAME PARENT OR GUARDIAN

SIGNED

DATE

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

Complete this section if you live in another EEA 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. If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

DO YOU HAVE A NON-UK EHIC OR PRC?

Yes No

IF YES, PLEASE ENTER DETAILS FROM YOUR EHIC OR PRC BELOW:

COUNTRY CODE:

NAME:

GIVEN NAMES:

DATE OF BIRTH

PERSONAL IDENTIFICATION NUMBER:

IDENTIFICATION NUMBER OF THE INSTITUTION:

IDENTIFICATION NUMBER OF THE CARD:

EXPIRY DATE:

PRC VALIDITY PERIOD (Date from and to)

PLEASE 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.

I have an S1 from

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 The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

NEW PATIENT REGISTRATION QUESTIONNAIRE 2021

Welcome to the Queen Edith Medical Practice. Please take a few minutes to complete this questionnaire as fully as possible.

Next of Kin

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

Consent to SMS and Email Contact

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address.

We may contact you with appointment details, test results, health campaigns or Patient Participation Group details

1. DO YOU AGREE THAT YOU MAY BE CONTACTED FROM TIME TO TIME, VIA EMAIL AND/OR SMS, WITH PRACTICE NEWS, ADVICE ABOUT MY HEALTH AND/OR APPOINTMENT REMINDERS. *

Yes

Additional Information For Children Under 16 Years Of Age

Name of parent/main carer *

Relationship to child *

Name and dates of birth of siblings *

Name of school

Communication Needs

What is your first language? *

Do you have a learning disability? *

Yes No

Do you speak English *

Yes No

Do you need an interpreter? *

Yes No

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Medical History

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

Alcohol

How often do you have a drink containing alcohol? *

SCORES OF 5 OR MORE REQUIRES THE FOLLOWING 7 QUETIONS TO BE COMPLETED: 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?

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

How often have you had 6 0r more units if female, or 8 or more if male, on a single occasion in the last year? *

Smoking

Height & Weight

Height

Weight *

Women

Have you ever had a cervical smear?

Yes No

If 'yes', please state when, where and the result

DO YOU USE CONTRACEPTION? IF YES STATE FORM USED:

Further Details

Sharing Your Health Record

What is your health record?

Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

· Sharing your contact details This will ensure you receive any medical appointments without delay
· Sharing your medical history This will ensure emergency services accurately assess you if needed
· Sharing your medication list This will ensure that you receive the most appropriate medication
· Sharing your allergies This will prevent you being given something to which you are allergic
· Sharing your test results This will prevent further unnecessary tests being required

Is my health record secure?

Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?

Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?

Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?

If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?

If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?

Queen Edith Medical Practice will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see: www.nhs.uk/NHSEngland/thenhs/records

For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters

Which Pharmacy would you like your prescriptions to be sent to? *

Are you happy to have a Summary Care Record? Information can be found: https://digital.nhs.uk/services/summary-care-records-scr/summary-care-records-scr-information-for-patients *

Yes No

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

I consent to your GP Practice sharing your health record with other organisations who care for you?

I consent to your GP Practice viewing your health record from other organisations that care for you

I dissent to your GP Practice sharing your health record with other organisations who care for you?

I dissent to your GP Practice viewing your health record from other organisations that care for you

Do you want to register for on-line services? *

Yes No

Signature

Signature *

Date *

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New Patient Questionnaire - QEMP

Further Information