Health Information Form - Adults

Title

First names

Surnames

Previous surnames

Date of Birth

Gender

Town and country of birth

NHS Number

Address

Home Telephone

Work Telephone

Mobile Telephone

Do you consent to being contacted by SMS on this number

Do you consent to being contacted by email at this address

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 or health campaigns

Next Of Kin Details

Next of Kin Name

Next of Kin Telephone

Relationship to you

Family Registered With Us

Communication Needs

What is your main spoken language?

Do you need an interpreter?

Do you have any communication needs?

Carer Details

Are you a carer?

Do you have a carer?

If yes please provide the details below. Only add carer’s details if they give their consent to have these details stored on your medical record

Carer's name

Telephone

Relationship to you

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Asthma

COPD

Epilepsy

Heart Disease

Stroke

Blood Pressure

Diabetes

Kidney Disease

Liver Disease

Depression

Thyroid

Cancer

Other

Allergies

Please record any allergies or sensitivities below

Current Medication

Please check and include as much information about your current medication below. Please give us your previous repeat medication list if possible and a medication review appointment may be needed

Are any of your regular medications prescribed by another Health Care Provider (i.e. from abroad)

If yes, please list the medications below

Alcohol

Please answer the following questions which are validated as screening tools for alcohol use

How often do you have a drink containing alcohol?

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

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?

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?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Smoking

Do you smoke?

Do you use an e-Cigarette?

How many cigarettes did/do you smoke a day?

Would you like help to quit smoking?

Height, Weight & Blood Pressure

Height

Weight

Blood Pressure

Women Only

Do you use any contraception?If needed, please book appointment.

Are you currently pregnant or think you may be?

If yes, what is your expected due date

Electronic Prescribing

If you would like your prescriptions to go electronically, please provide details of the pharmacy you would like to use

Patient Participation Group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group?

Sharing Your Health Record

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

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

Your Summary Care Record (SCR)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

Next Step

The practice will be in contact to collect ID and registrations can take up for 5 working days from receipt of ID, and the registration will not be processed without ID unless prior approval has been granted

I am aware that the registration won’t be accepted until identification is provided to the practice

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to James Fisher Medical Centre • 4 Tolpuddle Gardens, Muscliffe, Bournemouth, BH9 3LQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.