Get documents about "Clapham Family Practice
Document Sample
1
CLAPHAM FAMILY PRACTICE
NEW PATIENT REGISTRATION INFORMATION
Dear New or Returning Patient
Thank you for taking the time to fill these forms. This information enables us to ensure that we can deliver
services more effectively.
It is important that each question is answered. If you need help with any part of this form please speak to the
receptionists.
Please remember that information held in your medical records is confidential and will only be shared with
your consent.
Clapham Family Practice has a zero tolerance to prejudice on the basis of age, ethnicity, gender or sexuality
Public health research often requires the collection of annonymised data about large numbers of people. This
practice is part of Lambeth DataNet, and population information is used to ensure that services developed
locally accurately reflect the varied needs of the population.
All patients are encouraged to have a health check. Health checks are carried out by our nursing team and
include weight, height blood pressure, urine and blood tests as appropriate. Please ask at reception for an
appointment.
The NHS is a free service for those who are entitled to it. The role of Primary Care Clinicians is to assess your
condition and decide the best method of investigation or management. Onward referral to specialist services on
the NHS or under Private insurance is based on need and often requires investigations and treatments to be
provided in primary care over many months. Very often hospital specialist clinics are staffed by doctors or
nurses with a lot less experience than the doctors at the practice. We want to minimise the amount of time you
spend waiting for unnecessary hospital appointments.
Further information about the services we provide is available on our website
__________________________________________________________________________________________
Part 1 General Information
Name DOB
Your email address
Telephone Home: Mobile: Work:
Are you a carer? Y/N
(do you assist a friend or relative with daily living)
Are you cared for? Y/N
Does a friend or relative help you with daily living
Nationality/ Language
What is your Country of birth? Do you need an interpreter or
Translator?
What do you consider you nationality? Can you read English?
What is your main spoken language? Do you need large print?
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
2
What language do you prefer to read? Do you use lip reading?
Someone helped me to fill in this form Do you rely on British Sign
Language
Religion and Ethnicity
What is your religion? (If none please state none):
Please tell us your ethnic group (circle the appropriate Group under one heading)
1 Asian or Asian British 2 Black or Black British
Bangladeshi African
Indian Caribbean
Pakistani Any other Black background
please state
Other Asian Background please state
3 White 4 Mixed Background
British White and Asian
Irish White and Black African
Any other white please state White and Caribbean
Any other mixed please state
5 Chinese or other ethnic group
Chinese
Any other Ethnic group please state
Are you an asylum seeker? Are you a refugee?
Next of Kin
Name Relationship
Address Telephone Number
Part 2 Lifestyle
Are you a single parent?
How would you describe your sexuality Heterosexual
Bisexual
Gay
I reserve the right not to answer this question
Do you currently smoke? If yes how many per day?
Have you ever smoked? When did you stop?
How many did you smoke per day?
Do you want help to stop?
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
3
Do you have private medical Insurance Yes No
Alcohol Screening
1 drink/ unit= ½ pint of beer/ 1 small glass of wine/ 1 single spirit
Do you drink alcohol How H how many drinks/units would you
usually drink in one week?
Alcohol Screening is part of a National approach to targeting services
I reserve the right not to complete this alcohol screen Yes No
Please circle which ever applies
How often do you have eight or more drinks on one occasion?
Never 0 Less than monthly 1 Monthly 2 Weekly 3 Daily or nearly daily 4
How often in the past year have you been unable to remember what happened the night before because
of your drinking?
Never 0 Less than monthly 1 Monthly 2 Weekly 3 Daily or nearly daily 4
How often in the past year have you failed to do what was normally expected of you because of your drinking?
Never 0 Less than monthly 1 Monthly 2 Weekly 3 Daily or nearly daily 4
Has a friend, a doctor or other health care worker been concerned about your drinking
or suggested that you cut down?
Never 0 Yes nut not in the past year 2 Yes during the past year 4
A score of 3 or more is considered hazardous drinking; if you feel that your drinking is becoming out of
control please book an appointment with a doctor to discuss this
Depression Screening
Depression screening is a practice specific initiative
I reserve the right not to complete the depression screen Yes No
In the past two weeks how often have you been bothered by any of the following problems?
1: Little interest or pleasure in doing things
Never 0 Several Days 1 More than half the days 2 Nearly every day 3
2: Feeling down depressed or hopeless
Never 0 Several Days 1 More than half the days 2 Nearly every day 3
3: Trouble falling asleep of sleeping too much
Never 0 Several days 1 More than half the days 2 Nearly every day 3
4: Feeling tired or having little energy
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
4
Never 0 Several days 1 More than half the days 2 Nearly every day 3
5: poor appetite or overeating
Never 0 Several days 1 Moe than half the days 2 Nearly every day 3
6: feeling bad about yourself, or that you are a failure or that you have let yourself or family down
Never 0 Several days 1 More than half the days 2 Nearly every day 3
7: Trouble concentrating on things such as reading the newspaper or watching TV
Never 0 Several days 1 More than half the days 2 Nearly every day 3
8: Moving or speaking so slowly that other people could have noticed/ or the opposite being so fidgety or restless
that you have been moving around a lot more than usual
Never 0 Several days 1 More than half the days 2 Nearly every day 3
9:Thoughts that you would off dead or of hurting yourself
Never 0 Several days 1 More than half the days 2 Nearly every day 3
Depression Severity: 0-4 None, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.
If you are concerned please book an appointment to see a doctor
Part 3 Family Medical History
Does any member of your immediate family (parents, brothers, sisters, aunt uncle) suffer from any of these
illnesses?
Condition Yes/No Relative Condition Yes/ No Relative
Heart disease in a High blood
Relative under age pressure
60
Heart disease in a
Relative over 60
Stroke Asthma
Diabetes Epilepsy
Part 4 Personal Medical History
Do you suffer from any of the following conditions?
Condition Year diagnosed Condition Year diagnosed
Asthma Heart disease
Epilepsy Atrial fibrillation
HIV Cancer
Kidney disease Depression
Diabetes Bipolar disorder
High blood pressure Schizophrenia
Learning difficulty Chronic airways disease
Hypothyroidism
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
5
Have you any allergies? Yes/no
Have you had any other serious illness or operations?
Condition Year
1
2
3
4
5
Are you currently taking any medication?
Medication Dose
1
2
3
4
5
What is your current weight and height?
Weight
Height
Women age over 25 only:
When was your last smear? Result?
Please supply dates of any other abnormal smears
Women over 50 only
When was your last mammogram?
For young ladies between 16 and 19
HPV vaccine is available for you. This is the vaccine which prevents against the virus which can lead to cervical
cancer. Please book with a nurse to discuss this.
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
6
I have already completed a course of HPV vaccine
I do not wish to have the vaccine
For males and females between 16 and 25
Chlamydia testing is recommended for you. Chlamydia is a significant public health concern in Lambeth.
This particularly affects people male and female between 16 and 25. The test is simple and you can do it
yourself. Please ask at reception for the test pack
I have had Chlamydia screening within the past 6 months
I do not wish to have Chlamydia screening
HIV Screening
British HIV Association guidelines and the Department of Health recommend that all new GP registrations
are tested for HIV. Lambeth has the highest rate of HIV in the UK with over 1.2% of the population of
Lambeth being positive. Clapham Family Practice has a policy of strongly suggesting that our patients be
tested. You will find a blood test form with this pack: please book an appointment now or you can have the
test when you have your health check. A full screen for blood borne viruses will be carried out
I agree to have a HIV Test
I do not agree to have HIV test I have had one recently
I do not need to have one
Personal preference
Cardiovascular Risk assessment
Clapham Family Practice has a keen interest in prevention and we actively assess cardiovascular risk on our
patients aged 35 to 74, Please book for a health check and blood test if you are within this age range.
Please note: that you may be contacted to arrange an appointment with the appropriate clinician
depending on the information that you have provided in these forms
Part 5 Practice/ Patient Contract
This is a formal contract between Clapham Family Practice and you our new or returning patient.
Appointments
At the request of the Department of Health and as a result of public demand the practice operates a varied
system to make appointments. Appointments can be made up to 4 weeks in advance. A majority of
appointments are available within 2 working days. There is overwhelming support among our patients for this
system though it does not suit everyone. We will endeavour to give you an appointment within 2 working
days with the doctor of your choice, where this is not possible you will be advised of the appropriate time to
call back.
Telephone appointments are also available daily. A message will be taken and the doctor will phone you back
after morning surgery.
I have been made aware of the appointment system operating at the practice
Signed:
Prescriptions:
Not all medications are prescribed as repeat prescriptions. If you have not been prescribed a medicine at this
practice before, you will need to see a doctor for the first prescription. Requests for repeat prescriptions take 2
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
7
working days to process. This ensures that medicines are prescribed appropriately and safely. Repeat
prescriptions must be reviewed in some cases every six months others annually, you may therefore be asked
to make an appointment before having your medicine prescribed.
If you need someone else to collect prescriptions for you we will need your consent.
I give consent for to collect prescriptions on my behalf.
This consent is to remain in force until further notice from me.
Signed: (NB we are unable to hand out prescriptions to persons under the age of 16)
Messages/ Test Results:
In accordance with the Data Protection Act we need consent from any patient that has an answer phone for us
to leave a message. If you do not give consent we will be unable to leave a message on an answer phone, with
a third party or to send a text message
The practice will not give test results to a third party without your prior consent.
Please delete as appropriate
I give/ do not give consent to the practice to give results of tests/messages to:
I give/ do not give consent for the practice to leave a message regarding results at this number:
I give/do not give consent for the practice to text me about test results at this number:
I give/do not give consent for the practice to email me test results at this email address:
Practice Leaflet
I have been given a practice leaflet and have familiarised myself with its contents
Disclosure
I agree to disclose all material facts regarding my healthcare to practice clinicians. The practice agrees that
we will not share any information about you without your consent. Referrals to social services or specialist
services which are made at your request imply consent.
Appointments
I agree to attend on time for all appointments. I agree to call the practice to cancel any appointments that I
cannot attend. I acknowledge that should I arrive late for an appointment I may be asked to rebook. I accept
that the practice has the right to remove me from the list if I do not adhere to this agreement. The practice
agrees to notify you if your appointment is being cancelled by the practice and offer you an appropriate
alternative.
Contraception
Pill checks and contraceptive advice are carried out by the nurses in the practice. If you wish to discuss or
commence contraception please make an appointment with a nurse. Not all our GPs are trained in
contraception advice, the nurses are, so please do not be offended if they refer you to a nurse. The pill will
initially be prescribed for 3 months. Subsequent prescriptions will usually be for a maximum of 6 months
occasionally 12 months. Pill prescriptions are never provided as repeat prescriptions. You must be checked
by the nurse for each prescription. Please do not be ask for a repeat of the pill at reception as they will not be
able to oblige. Condoms are available at reception
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
8
Pregnancy Tests
Pregnancy tests are available free from reception and can also be bought at chemist shops. Please do not
make an appointment with a doctor or nurse for a pregnancy test.
Emergency Appointments
I acknowledge that the practice operates on an appointment system and that I will be offered an appointment
within two working days or a telephone consultation when appropriate. I acknowledge that a limited number
of emergency appointments may be available each morning for conditions that are regarded by the patient as
medical emergencies which have arisen in the previous 48 hours and require immediate medical treatment. I
appreciate that this is a triage service and may result in a request that I make a routine appointment. I am
aware that sick notes or repeat prescriptions will not be entertained in emergency appointments.
Home Visits
A doctor can see 8 patients during the time it takes to visit a patient at home. Home visits ought to remain
confined to house bound patients. I agree that when possible I will only request a home visit when I am
unable to come to the surgery and I will request a visit no later than 11:00am. I acknowledge that if I request
a home visit the on call doctor will telephone me and advise me of the most appropriate care option. Home
visits can only be to your registered address.
Out of Hours Services
I agree to use the out of hour’s service only when it is medically necessary. This includes use of accident and
emergency services and ambulance services. Between 8am and 8pm on weekends and bank holidays patients
of the practice can book an appointment or drop in to the NHS Health Centre at Gracefield Gardens in
Streatham. Buss number 50 from Clapham High Street.
Mobile Phones
I agree to switch off my mobile phone and other electronic devices before entering the practice and to keep it
switched off at all times whilst in the practice. I accept that if my phone should ring during a consultation the
consultation will cease and I will be asked to rebook.
Zero tolerance
The practice has a zero tolerance for prejudice on the basis of race, creed, gender or sexuality. This applies
to patients as well as staff. I accept that the practice can remove me from the list if I behave in an abusive,
aggressive, threatening manner to any other patient or to a staff member.
Food and Drink
I agree that it is unacceptable to consume food or drink or to smoke within the practice premises. I agree not
to attend appointments under the influence of drugs or alcohol.
Patient Group
The practice has a patient group which advises on services and administration.
Would you be prepared to put your name forward for this group when a vacancy arises? Yes/No
Aside from this group we are happy to accept suggestions and comments from all our patients.
Signed
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
9
Name:
Date:
For office use only:
Staff initials Date
Identity, eligibility and proof of address
checked
Health check appointment offered
Practice booklet and information leaflets
given to patient
Registration forms checked
Copy of contract given to /sent to patient
Registration completed
Appropriate appointments offered
CLAPHAM FAMIIILY PRACTIIICE PATIIIENT REGIIISTRATIIION FORMS
CLAPHAM FAM LY PRACT CE PAT ENT REG STRAT ON FORMS
LAPHAM AM LY RACT CE AT ENT EG STRAT ON ORMS
