RADFORD MEDICAL PRACTICE 
Surname/Family Name
	
Forenames/Given Name
	
Date of Birth (please print in full)	Have you just arrived from abroad? If so, please state which country: 

Are you an asylum seeker?
Yes/No	
Nottingham address: (please include the flat and room number if appropriate)

Mobile Telephone number:

E mail:	If you are aged 18 or under please give the detailsA of your parent/guardian
Name:

Address:

Relationship to you: 

No  

Main language spoken:
Do you require an interpreter?     Yes	

	Ethnic origin:
White British
Other White background
White & Asian
Other mixed background
Pakistani
Black Caribbean
Other black background
Other Asian background
Other ethnic group - please state	

	
White Irish
White & Black Caribbean
White & Black African
Indian
Bangladeshi
Black African
Chinese
I prefer not to say
	
Do you smoke?
        Never                         Previously smoked                  Currently smoke                                      
                                                                                                    Amount per day …..	
Do you drink alcohol?
Yes    No     	Height:
…………	Weight:
…………..	

	

If YES, how many units per week: ……..… (1 unit = 1 measure spirit / 1 glass wine / ½ pint beer)	

How many times do you exercise per week? …………………… type of exercise……………………….	
Do you have any allergies?

Are you allergic to any medication?

Have you had any surgical operations?	

	Yes

Yes

Yes	

	No

No

No	please state………..…..

please state………....…

please state ……..….…	

MEDICAL HISTORY
	
Have you suffered from any of the following?	

Heart problems
Stroke / Transient Ischaemic Attack
Asthma
Diabetes
Epilepsy (Date of last fit:……………   ) 
High blood pressure
Thyroid problems
Depression
Schizophrenia / Bipolar Affective Disorder
Cancer
Kidney disease
An eating disorder	Yes

	No

	  Date of onset

…………....……
…………….……
……………....…
……………....…
……………....…
……………....…
……………….…
……………….…
……………….…
……………….…
……………….…
…………………	
Has anyone in your family had:
High blood pressure
Diabetes
A heart attack before age 60?
A stroke before age 60?	

	

	Which relative
…………………
…………………
…………………
…………………	

Do you have a disability? (if yes, please state............................)
Are you registered disabled?
Do you have a Carer?
Are you a Carer for somebody?	

	
Yes
Yes
Yes
Yes	

	
No
No
No
No	

Is there any other information you would like us to know that is relevant to your health care not mentioned above? Please state: 

We would like to contact you by text message or by email to remind you of your booked appointments, if you need to contact the practice for a review, to share information about our services or to gain your feedback on services we provide.  

If you wish to receive text appointment reminders and information via text and email please sign here:  ……………………………………….

Do you have any information or communication needs?  YES              NO 
If yes, what are they:
What is your preferred method of contact:
	
For surgery use only:
Entered by:                Date:                  EMIS code:	
	
NEW PATIENT QUESTIONNAIRE 

SUMMARY CARE RECORD
A summary care record is an electronic record of important information about your health. It will be available to health care staff providing your NHS care. In the case on an emergency this allows other NHS healthcare agents to gain access to information about you including details of your medications, allergies and any other relevant information. Please read our ‘Summary Care Record’ leaflet for more detailed information.

Please tick one box below to indicate your preference.
I would like a Summary Care Record containing details of my medications, allergies and any bad reactions to medication.		
I would like a Summary Care Record containing details of my medications, allergies, bad reactions to medication AND any additional information useful for my care.		

If you DO NOT wish to have a Summary Care Record please ask for an opt-out form at reception.

ACCESS TO GP ONLINE SERVICES
The clinical system we use at Radford Medical Practice is called EMIS. This system offers patients over the age of 16 the option to enrol in online services in order to book appointments, request repeat prescriptions and access their summary care record through a web page or app.  If you are not the patient (ie. You are a parent or carer) and you wish to access these online services on their behalf then please ask for information about proxy access. 

If you would like to enrol in this service please ensure you bring one form of photographic ID (passport or driving license) plus an additional proof of address when returning this form.

I wish to have access to the following online services (please tick all that apply):	
Booking appointments		
Requesting repeat prescriptions		
Summary Care Record		

Patients Signature:	Date:

ONLINE ACCESS TO YOUR DETAILED CODED RECORD
EMIS offers patients the option to see their detailed coded record online via a webpage or app.  A detailed coded record includes the following information: 
•	Demographic
•	Allergies/adverse reactions
•	Medication (dose, quantity, last issued date)
•	Immunisations
•	Results (numerical values and normal ranges)
•	Values (BP, PEFR)
•	Problems/diagnoses
•	Procedure codes (medical or surgical) and codes in consultation (signs, symptoms)
•	Codes showing referral made or letters received (no attachments)
•	Other codes (ethnicity, QOF)
Detailed coded records do not contain free text or letters and so may not always be easy to understand. Please read our leaflet ‘Accessing GP Records Online’ for more information on this service and some abbreviations that might help you.

If you wish to have access to your detailed coded records, please ask for a form at reception.