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Patient's Details

 NEW PATIENT MEDICAL QUESTIONNAIRE 
ADULTS and children aged 12 years and over

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Please enter DD/MM/YYYY
If you do not have an NHS number type 'None'
 
 
 
Emergency Contact
 
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Ethnicity & Religion
Sensory impairment, disability or assistance
Carers
 
 
 
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Lifestyle
Please use the machine in the waiting room or your own monitor to take 3 readings and enter the results.

IF YOU ARE NOT ABLE TO PROVIDE YOUR BLOOD PRESSURE ON THIS FORM PLEASE POP INTO THE SURGERY TO USE THE MACHINE IN OUR WAITING ROOM AND GIVE THE READINGS TO RECEPTION. 

For more information and support around quitting please visit Stop For Life Oxon

Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

 
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Adult Females
Please use this date format: DD/MM/YYYY. If you are over 25 have never had a cervical cancer screening test, please write 'Never' and make an appointment with the surgery.
If outside the UK, the practice may need to contact you.
Medical History
Please include dates.
Please include dates.
Family History
Please include the relationship and age of relative if known.
 
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Immunisation History
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
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If none or not known please write in.
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If none or not known please write in.
If none or not known please write in.
If none or not known please write in.
Allergies
 
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

 
 
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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

 
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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.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent - Mandatory question (you cannot proceed without answering)

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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