Seascale Health Centre New Patient Questionnaire
New Patient Questionnaire
Please take the time to complete this questionnaire; it will help us to gather important
information to ensure we manage your most important health requirements.
Full Name Previous Surname(s)
Date of Birth Place of Birth
Tel. No Home Mobile No
Address
Email address
Other family members at this address
Next of Kin Name
Tel. No Home
Mobile No
Address
Relationship to you
Do they permission to discuss your record? Yes / No
Mobile Phone Consent
If you provide us with a mobile number you are automatically opted in to receive appointment reminders
and information messages via SMS from Seascale Health Centre.
Online Access
Would you like to be registered for online access to your records? Yes / No
Would you like to receive your instructions and pin number via e-mail? Yes / No
Please indicate your ethnic origin
Main Spoken Language
Carers: Do you look after someone or does someone regularly help you? Please give details below
Do you have any sensory impairments or communication needs that we should know about? i.e. wear
hearing aid, would like correspondence in large print?
Height in cm Weight in kg
Do you smoke? Yes No Ex-Smoker E-Cigarette
Cigs per day Date given up
Oz per day
A White B Mixed C Asian or Asian British
D Black or Black British E Chinese or other ethnic group
British White and Black Caribbean Indian Caribbean Chinese
Irish White and Black African Pakistani African Any other
Please specify Other White and Asian Bangladeshi Any other black background
Any other Mixed background Any other Asian
Seascale Health Centre New Patient Questionnaire
Family History: Do you have any family members who have had the following?
Relationship to you
Diabetes Y/N
Stroke Y/N
Thyroid Disease Y/N
Heart Attack Y/N
Asthma Y/N
Cancer Y/N
Glaucoma Y/N
Any other important family illnesses?
Do you have any allergies?
Have you been diagnosed with any of the following?
Diabetes Type 1 Diabetes Type 2 Chronic Heart Disease
Chronic Kidney Disease Cardiovascular Disease Asthma/COPD (Respiratory Disease
Cancer Stroke Epilepsy
Depression Dementia Other - Please Specify
Have you had any operations, major illnesses or medical conditions?
Date/Year Details
Are you on any repeat medication?
Drug Name Dosage Times taken daily
Do you have any health concerns at present?
Today’s date
Seascale Health Centre New Patient Questionnaire
Patient Name Date of Birth
Complete the 3 questions in AUDIT-C first. If the score is 5 or more the full AUDIT
questionnaire should be completed
AUDIT – C
Scoring system Questions
0 1 2 3 4
Your
score
How often do you have a drink containing
alcohol? 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?
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?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
AUDIT-C score
Scoring:
A total of 5+ indicates increasing or higher risk drinking in which case the remaining AUDIT questions
need to be completed.
Seascale Health Centre New Patient Questionnaire
Score from AUDIT- C (other side)
Remaining AUDIT questions
Questions Scoring system
Your
score 0 1 2 3 4
How often during the last year have you found
that you were not able to stop drinking once you
had started?
Never
Less
than
monthly
Monthly Weekly
Daily or
almost daily
How often during the last year have you failed to
do what was normally expected from you
because of your drinking?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
How often during the last year have you needed
an alcoholic drink in the morning to get yourself
going after a heavy drinking session?
Never Less than
monthly Monthly Weekly
How often during the last year have you had a
feeling of guilt or remorse after drinking? Never
Less than
monthly Monthly Weekly
Daily
or almost daily
How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
Never Less than
monthly Monthly Weekly
Daily
or almost daily
Have you or somebody else been injured as a
result of your drinking? No
Yes, but not
in the last year
Yes, during
the last year
Has a relative or friend, doctor or other health
worker been concerned about your drinking or
suggested that you cut down?
No
Yes,
but not in the last year
Yes,
during the last year
Full total AUDIT Score
Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence
For office use only:
Photo ID seen Code 9RN added to care history
Comments ………………………………………………………………………………………………….
Seascale Health Centre New Patient Questionnaire
Patient Agreement
Between:
Seascale Health Centre (including Bootle Surgery), Gosforth Road, Seascale, CA201PN
AND
Patient Name Date of Birth
Thank you for joining the Seascale Health Centre. This agreement outlines our commitment from us to
you as a patient. It also outlines our expectations from you. Having a mutual understanding of this
agreement will enable us to give you the best possible care.
Our Commitment
• To provide you and your family with the best possible primary health care.
• To treat all our patients and visitors to the practice with courtesy, respect and dignity at all times.
• To progress your treatment as efficiently as possible.
• To meet all our responsibilities with respect to confidentiality.
• To issue repeat prescriptions following approval by a GP, providing we are given 48 hours notice.
Your Commitment
• To afford us the same courtesy, respect and dignity as you expect from us.
• You will not undertake any abusive behaviour both verbal and physical towards any doctor or
member of staff.
• If you have grievances against any member of staff, you should make an appointment to see the
practice manager. You should not discuss your grievance with the member of staff concerned.
• You will not present at the surgery and expect to be seen by a doctor or nurse immediately unless
you have a life-threatening complaint. You should otherwise make an appointment to be seen in
the usual way.
• You will behave in an acceptable way in the Reception area when attending the surgery, taking
account of other patients around you.
• You will be prepared to see any member of the practice team. You cannot insist on particular
members of staff carrying out any specific duties.
• You will advise us if you cannot keep an appointment.
• You will only request a home visit, if absolutely necessary.
• You will use a telephone consultation whenever possible, especially for test results.
• To remember doctors are human too and they cannot always solve all your problems.
• To contact the practice manager directly with any complaint.
AGREEMENT
If it is felt that your behaviour is inappropriate, our staff will:
• ask you to leave the premises
• if necessary we will seek police assistance
• consider removing you from the list
Please note that all of the above is what we would normally expect from all our patients
Understood and agreed by:
Patient Name Signature
Doctor Name Signature
Practice Manager Name Signature
Date
Seascale Health Centre New Patient Questionnaire
NHS Record Sharing
Seascale Health Centre Practice Data “Opt Out” Form
Please complete the form below if you wish to opt out from NHS Record Sharing. Information about this
is available on our website or from reception.
Patient Name
Date of Birth
Address
I am the patient (or guardian of the patient) named above. I have read the patient information and have
decided that I do not wish to share my Record with other Health Care Professionals. (Please tick
appropriately below)
Your GP records (EMIS) Signature
Summary Care Record (9Nd0) Signature
(National within the NHS)
Care Data (9Nu0)(Data only) Signature
Dissent from secondary use of general practitioner patient identifiable data.
By signing this form I understand that my GP Practice will disable sharing of my Medical record and as a
result only health care professionals working in my practice will have access to my medical records.
Patient Signature Date
Office: Coded by Date
Seascale Health Centre New Patient Questionnaire
Seascale Health Centre New Patient Questionnaire
Seascale Health Centre New Patient Questionnaire
Application form for access to the practice online services.
Before you apply for online access to your record, there are some other things to consider.
Although the chances of any of these things happening are very small, you are asked that you have read
and understood the following before you are given login details.
Things to consider
Forgotten history
There may be something you have forgotten about in your record that you might find upsetting
Abnormal results or bad news
If your GP has given you access to test results or letters, you may see something that you find upsetting.
This may occur before you have spoken to your doctor or while the surgery is closed and you cannot
contact them.
Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers.
It’s your choice, but also your responsibility to keep the information safe and secure.
Coercion
If you think you may be pressured into revealing details from your patient record to someone else against
your will, it is best that you do not register for access at this time.
Misunderstood information
Your medical record is designed to be used by clinical professionals to ensure that you receive the best
possible care. Some of the information within your medical record may be highly technical, written by
specialists and not easily understood. If you require further clarification, please contact the surgery for a
clearer explanation.
Information about someone else
If you spot something in the record that is not about you or notice any other errors, please log out of the
system immediately and contact the practice as soon as possible.
More information
For more information about keeping your healthcare records safe and secure, we recommend that you
read
Protecting your GP Online Records
https://www.england.nhs.uk/wp-content/uploads/2016/11/pat-guid-protecting-your-records.pdf
and this helpful leaflet produced by the NHS in conjunction with the British Computer Society:
Keeping your online health and social care records safe and secure
https://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/PatientGuidanceBooklet.pdf
Seascale Health Centre New Patient Questionnaire
First Name Surname
Date of Birth Place of Birth
Tel. No Home Mobile No
Address
Email address
I understand that my email address and/or mobile number may be used by the practice to contact you to
provide health and care services. For example:
appointment reminders
health campaign messages
messages relating to your own health and care e.g. test results
surveys about our services
If you do not wish to be contacted by either of the following please tick:
Mobile
I wish to have access to the following online services (please tick all that apply):
1. Booking appointments □
2. Requesting repeat prescriptions □
3. Sending secure messaging □
4. Access to detailed medical record □
5. Proxy Access to records for family members who I care for with separate login details □
I wish to access my online services and understand and agree with each statement (tick)
1. I have read and understood the information provided by the practice □ 2. I will be responsible for the security of the information that I see or download □ 3. If I choose to share my information with anyone else, this is at my own risk □ 4. If I suspect that my account has been accessed by someone without my agreement, I will
contact the practice as soon as possible
□
5. If I see information in my record that is not about me or is inaccurate, I will contact the
practice as soon as possible
□
6. If I think that I may come under pressure to give access to someone else unwillingly I will
contact the practice as soon as possible.
□
7. If I see something in my records that I am unsure of and have not yet been contacted by
the surgery, I will wait until usual opening times and not contact the out of hours or
emergency services
□
Signature Date
For Office Use Only Date clinical assurance completed
Date account created Assured by (initials)
Date account details given Reason for refusal if applicable
Level of access created
Detailed coded record □
All prospective □
All retrospective □