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Lime Tree New Patient Form – 16 and over

Please complete all details as fully as possible

Dr / Mr / Mrs / Ms / Miss / Other: …………… NHS Number:……………………………………..

Surname: Previous Surname(s):

First Names: Date of Birth:

Ethnicity:

Why we ask: Some results (eg. bloods) are different for people of different ethnic backgrounds so interpret differently. Some ethnicities are at higher risk from certain conditions/ diseases; we want to be more able to identify any problems quickly. Please leave blank if you’d rather not say.

Main Language:

Interpreter required: YES NO

Address:

Postal Code: Religion:

Why we ask: Some religions do not allow certain medical procedures (i.e. blood transfusions) or prohibit using animal products (e.g. pork gelatine) that are sometimes in vaccinations.

Marital Status:

Home Tel No: Work Tel No:

Mobile No: Email address:

Occupation: Which site would you like to register at?

Goring / Findon / Durrington

ACCESSIBLE INFORMATION STANDARD

All service providers across the NHS & adult social care system must by law, follow The Accessible Information Standard. This aims to ensure that all people with a disability, impairment or sensory loss have access to information they can understand and the communication support

they may need, this includes parents and carers of patients who have such communication needs. For most of us our preferred method of contact is our home number or mobile number but, for

example, if you are hard of hearing that method may not be suitable for you. If you would prefer us to make contact in another way, please inform us of the most suitable way for us to communicate with you below. We will record your suitable method of communication in your medical records.

Do you have a disability, impairment or sensory loss and would prefer practice communications via a specific method more suitable for your needs? YES / NO If YES, please give your preferred method of communication/ indicate what you would like discuss: Please indicate your consent or dissent to the following:

Please note that consent to all the above will be assumed if no options are marked. This arrangement will remain in force until you advise us in writing that you wish to change it.

1. Do you consent to the surgery leaving a message with a third party or on your voicemail requesting you call us back?

YES / NO

2. Do you consent to the surgery sending you text messages or leaving you voicemails?

YES / NO

3. Do you consent to the surgery emailing you? YES / NO

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NEXT OF KIN

Full name:

………………………………………………………

Relationship to you:

………….…………………………………………..

Address:

………………………………………………………………………………………………………………

Tel No:

…………………………………………………………….

PRESENT ILLNESSES / OPERATIONS

Problem Date

□ Asthma

□ Cancer

□ Chronic Kidney Disease

□ COPD

□ Diabetes

□ Epilepsy

□ Heart Disease

□ On Treatment for High Blood

Pressure

□ Mental Health Problems

□ Stroke

□ Thyroid Disease

Problem Date

Please complete any other past medical history and if possible please provide dates. Try to be as specific as possible e.g. back op – hospital and reason

Do you have a carer? YES / NO Are you a carer? YES / NO

Carer’s name: …………………………… Cared-for person’s name……………………………

Office use; Carers forms given; date: ……………………… Rec Initials of staff member: ……………………….

Office use; Scheduled task sent to Carers Lead Admin

If you have any of these

illnesses please tick the box

next to them and complete

the date of onset in the

second column.

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FAMILY HISTORY Do you have any close blood relatives who have had any of the following?

Angina YES / NO Relationship(s)

Cancer YES / NO Relationship(s)

Diabetes YES / NO Relationship(s)

Heart Attack YES / NO Relationship(s)

Stroke YES / NO Relationship(s)

HEIGHT & WEIGHT

Height: feet & inches: ……………… or Metres & centimetres: …………………….

Weight: st. & lbs: …………………….. or Kilos: ………………………

EXERCISE

How much exercise do you take?

SMOKING/ VAPING

Please circle your answers: Smoking status Amount Daily Would you like help to stop?

1 Never Smoked

2 Ex-smoker <1 1-9 10-19 20-39 40+ What year did you give up?

3 Currently smoke <1 1-9 10-19 20-39 40+ YES NO

4 Currently Vape Occastional use Regular use YES NO

ALCOHOL

GP surgeries are required to ask the alcohol intake of all patients aged 16 years and over. If you fail to

provide your answer for any of the three questions, our system will not allow us to complete your

registration process. (Please circle your answer to all questions)

0 1 2 3 4

How often do you have a

drink that contains 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 have a day, when

drinking?

0 -2 3 - 4 5 - 6 7 - 8 10+

How often have you had 6

or more units on one occasion,

in the last year?

Never Less than

monthly Monthly Weekly

Daily or almost

daily

Unable to exercise Avoid exercise Light exercise

Aerobic exercise Aerobic exercise 2/w Aerobic exercise 3+/w

Q1)

Q2)

Q3)

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MEDICATION

Please list all medication you are currently taking and include proof of this medication from your previous surgery. An empty box or a repeat prescription slip will be adequate. This proof is needed before any medication can be issued.

Medication Dose Times Per Day

NHS Electronic Prescription Service The Electronic Prescription Service (EPS) is a free NHS service which allows

GP Surgeries to send your prescription to your chosen pharmacy, via a secure electronic connection, so you do not have to collect a paper copy from the surgery. Please indicate your preferred Pharmacy below (this

can be any pharmacy, no matter how far away they are from the practice as long as the name and postcode are stated).Please note that we require one form per patient.

Lime Tree Pharmacy Lime Tree Avenue, Findon Valley, Worthing BN14 0DL

Rowlands Pharmacy 5 the Waterfront, Goring-by-sea, Worthing BN12 4FD

LloydsPharmacy 4-6 Manor Parade, Durrington, Worthing BN13 2JP

Kamsons Pharmacy 326 Goring Road, Goring-by-sea, Worthing BN12 4PE

Tesco Instore Pharmacy New Road, West Durrington, Worthing BN13 3PB

Boots 21 Goring Road, Goring-by-sea, Worthing BN12 4AP

Boots Downland Business Pk, Lyons Way, Worthing BN14 9LA

Rowlands Pharmacy 8 AldsworthAvenue, Goring-by-sea, Worthing BN12 4UP

Other (please state & include postcode):

I am the patient named above/ carer of the patient named above.

Nomination has been explained to me and I have also read the leaflet that explains nomination.

I would like to nominate the Pharmacy above as my nominated pharmacy for dispensing

prescriptions issued by the NHS Electronic Prescription Service.

Signed…………………………………………..........

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IMMUNISATIONS

Please state what immunisations you have had e.g. cholera, diphtheria, influenza, MMR1, MMR2, pneumonia, polio, rubella, tetanus, typhoid, whooping cough etc.

Date Immunisation

ALLERGIES Allergy/Intolerance Date of onset Reaction

Patient Participation Group

The Patient Reference Group (PPG) is a group of patients with the aim of:

Providing constructive ideas to help us better our services

Raising funds for patient equipment not funded by the NHS

Helping with patient social groups such as walking group.

The PPG are invited to meetings to discuss new developments and ideas. Members of the

reference group are also asked to complete surveys and provide their opinions via email/ text; this

means that everyone can get involved, even if you cannot attend meetings.

Email: …………………………………………. Phone: ………………………………………….

Signed: …………………………………………………

Please leave this blank if you do not wish to participate

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SMEAR TESTS

If you are eligible for smear testing (generally women aged 25yrs to 64yrs), please provide the

following details:

The date of your last smear: ……………………………

Details of any abnormal smears: ………………………………………………………………

BLOOD PRESSURE

Please take your blood pressure using the machine in the waiting room.

The machine will print out your reading on a ticket, please write your name and date of birth on this and hand it in to a receptionist with this sheet. If you have a blood pressure reader at home, you are welcome to use that instead and give us the details.

Please sign below to state that the details you have entered on this form are correct and you are happy for this information to be entered on your medical records.

Signed:

Date:

Thank you for completing this form.

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Access to online Services This enables you to use our online services, to book appointments, order repeat prescriptions and gain access to your summary medical record online.

Patient Online - Access to GP online services

I wish to have access to the following online services (tick all that apply):

1. Booking appointments

2. Requesting repeat prescriptions

3. Accessing my summary medical record

4. Access to my detailed coded record

If you have said yes to number 3 or 4 and you are a new patient at Lime Tree Surgery then please note that

online access can take up to 3 months before it will be available as we will need to make sure your records are

accurate and up to date.

Please note that any requests for access to number 3 or 4 will take up to 10 working days to review your

application and grant access if appropriate. This may take longer in certain circumstances.

Once your online access has been approved, you will receive notification of this in the post.

Application for online access to my medical record

I wish to access my detailed coded record online and understand and agree with each statement (please tick)

1. I have read and understood the information leaflet 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. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

5. If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Signature

Date

For practice use onlyIdentity verified through

(tick all that apply)

Photo ID Proof of residence

Vouching Name of person vouching……………

Name of verifier

Date

Date account created

Date logon details sent

Approved by:

Records checked by:

Sign and date:

Surname

First name

Date of birth (aged 16yrs + only)

Address

Postcode

Email address

Telephone number Mobile number

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