Family doctor services registration

GMS1-JUL12_GMS 1 17/07/2012 13:15 Page 1 Family doctor services registration GMS1 Patient s details n Mr n Mrs n Miss n Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick n as appropriate 4 NHS No. n Male n Female Home address Previous surname/s Town and country of birth Postcode Telephone number Please help us trace your previous medical records by providing the following information Your previous address in UK Name of previous doctor while at that address Address of previous doctor 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 If you are returning from the Armed Forces Address before enlisting Service or Personnel number Enlistment date If you are registering a child under 5 n I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance If you need your doctor to dispense medicines and appliances* n I live more than 1 mile in a straight line from the nearest chemist n I would have serious difficulty in getting them from a chemist *Not all doctors are authorised to dispense medicines n Signature of Patient n Signature on behalf of patient Date / / Version 01/02 Please see overleaf re: Organ donation

GMS1-JUL12_GMS 1 17/07/2012 13:15 Page 2 Family doctor services registration GMS1 NHS Organ Donor registration I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming my agreement to organ/tissue donation Date / / For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk, or call 0300 123 23 23. NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Tick here if you have given blood in the last 3 years Signature confirming consent to inclusion on the NHS Blood Donor Register Date / / For more information, please ask for the leaflet on joining the NHS Blood Donor Register My preferred address for donation is: (only if different from above, e.g. your place of work) Postcode: To be completed by the doctor Doctors Name HA Code I have accepted this patient for general medical services For the provision of contraceptive services I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice Doctors Name, if different from above HA Code I am on the HA CHS list and will provide Child Health Surveillance to this patient or I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the HA CHS list and will provide Child Health Surveillance to this patient. Doctors Name, if different from above HA Code I will dispense medicines/appliances to this patient subject to Health Authority s Approval I am claiming rural practice payment for this patient. Distance in miles between my patient s home address and my main surgery is I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowances. An audit trail is available at the practice for inspection by the HA s authorised officers and auditors appointed by the Audit Commission. Practice Stamp Authorised Signature Name Date / / HA use only Patient registered for GMS CHS Dispensing Rural Practice

Kingsway Health Centre Registration Form. 385 Dunstable Road Luton Telephone: 01582 8487808 LU4 8BY Facsimile: 01582 592079 Please use BLOCK CAPITALS and answer all questions. The information provided will form part of your Medical Record. If you are returning from the Armed Forces, please let us know. Personal Details 1. Mr [ ] Mrs [ ] Miss [ ] Ms [ ] Other: Please specify 2. Surname: 3. First Names: 4. Previous Surname(s): 5. Male/Female 6. Date of birth: / / 7. NHS Number: (day) (month) (year) (if known) 8. Town and Country of Birth: 9. If you are from abroad, the date you came to UK: 10. Current Address: Postcode: 11. Home Telephone: 12. Work Telephone 13. Mobile Telephone: 14. Email: 15. Occupation (e.g. Health, Factory work, Retail, Construction, etc) Previous GP Details 16. Have you ever been registered with a GP in UK? Yes [ ] No [ ] 17. Name and address of last GP/Surgery: Postcode: 18. Your address while registered with that GP: Postcode: Signature 18a. Signature of Patient: 18b. Signature on behalf of Patient: 19. Date: Your Next of Kin / Emergency Contact 20. Next of Kin s Name: 21. Relationship to you: 22. Next of Kin s Address: 23. Telephone Numbers:

Ethnic Origin 24. Please choose from the following Groups in bold: (Please tick one box in relevant Group) White British [ ] Irish [ ] Any other White Background [ ] Please give details Black or Black British Caribbean [ ] African [ ] Any other Black Background [ ] Please give details Asian or Asian British Indian [ ] Pakistani [ ] Bangladeshi [ ] Any other Asian Background [ ] Please give details Mixed White and Black Caribbean [ ] White and Black African [ ] White and Asian [ ] Any other Mixed Background [ ] Please give details Chinese [ ] Other Ethnic Groups [ ] Please give details Marital Status 25. Please choose from the following Groups and tick the relevant box: Single [ ] Married [ ] Common Law Partnership [ ] Widowed [ ] Divorced [ ] Separated [ ] Language 26. My main written language is: (one only) 27. My main spoken language is: (one only) 28. Do you have any problems reading English? I have no problems [ ] I have some problems [ ] I have a lot of problems [ ] 29. Do you have any problems speaking English? I have no problems [ ] I have some problems [ ] I have a lot of problems [ ] 30. If English is not your main spoken language, do you need help from a relative or friend when you visit the doctor? Yes [ ] No [ ]

Current University students only 31. Are you currently a full-time or part-time University student? Yes [ ] No [ ] If No, please ignore the rest of this section. 32. Which University? Address Telephone Number 33. Course end date: 34. Are you an overseas student? Yes [ ] No [ ] Children attending School / Further Education only 35. Which School / College? Address Telephone Number Health 36. Do you take regular medication? Yes [ ] No [ ] If yes, please list on a separate sheet and attach. 37. Do you have any long-term illness, health problem or disability? Yes [ ] No [ ] 38. If Yes, please give details: 39. If Yes, does this limit your daily activities or the work you can do? Yes [ ] No [ ] 40. Do you have any of the following Disabilities? Not Disabled [ ] (Please tick box) Learning intellectual impairment Physical motor disability 41. Are you a Main Carer for anyone with the following Disabilities? Learning disabilities Physical disabilities 42. Do you have a Carer? Yes [ ] No [ ]

Females Only 43. When did you last have a Cervical Smear Test (over 25 years of age only) 44. When did you last have a Mammogram / Breast X-Ray (over 50 years of age only) Significant Past Medical History 45. Past Medical History (e.g. operations / illnesses) 46. Current Prescribed Medication 47. Do you or Family Members have any of the following conditions: Heart Problems Yes [ ] No [ ] Stroke Yes [ ] No [ ] High Blood Pressure Yes [ ] No [ ] Diabetes / Sufar Yes [ ] No [ ] Hypothyroidism Yes [ ] No [ ] Heart Attacks Yes [ ] No [ ] High Cholesterol Yes [ ] No [ ] Angina Yes [ ] No [ ] Cancer Yes [ ] No [ ] Breast Cancer Yes [ ] No [ ] Stomach Cancer Yes [ ] No [ ] Bowel Cancer Yes [ ] No [ ] Prostate Cancer Yes [ ] No [ ] Lifestyle 48. Do you live alone? Yes [ ] No [ ] 49. Do you provide care for someone because of their poor health or disability? Yes [ ] No [ ] 50. Do you smoke? I used to smoke [ ] I ve never smoked [ ] I smoke [ ] How many? [ ] cigarettes [ ] cigars [ ] per day 51. Do you drink alcohol? If Yes, how many Pints [ ] Glasses [ ] Measures [ ] (per week) of Beer/Lager [ ] Wine [ ] Spirits [ ] 52. Height? (approximate) 53. Weight? (approximate) 55. Diet? Meat eater [ ] Vegetarian [ ] Vegan [ ] Other [ ] Thank you for completing this form. The information you have provided will help us to plan our service better, in order to meet the needs of all our patients. This information will form part of your medical record. For more details about how we use your information, please see our practice leaflet.