New Patient Questionnaire - 4

Last Updated: 01/07/2022

Your Contact Details

Title

Name *

Date of Birth *

Previous Surname

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Information About You

Medical Information

Carers

Do you have a carer? *

Yes No

If yes please give details, including contact telephone number

Are you a carer? *

Yes No

(If yes please give details)

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

Q1. 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 more more units if female, or 8 or more if male, on a single occasion in the last year? *

Are you eligible for a free NHS health check?

Electronic Prescription Service

The service allows us to send your prescriptions electronically to one of the local pharmacies. If you would like to use this service, please choose from one of the following local pharmacies: *

Contacting You

Do you consent to us contacting you via SMS? (This would be for appointment reminders and invitations for healthscreening) *

Yes No

DO YOU CONSENT TO US CONTACTING YOU VIA email? (THIS WOULD BE FOR APPOINTMENT REMINDERS AND INVITATIONS FOR HEALTHSCREENING) *

Yes No

Data Sharing Preferences

This outlines the data that is being collected by the practice and the NHS to help with health care delivery and planning. This explains the difference between the records and how your information is shared, with whom and how you can opt out of these arrangements should you wish.

Summary Care Record (SCR)

This is a record that contains important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had. This does not include diagnosis or procedures. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or if your GP practice is closed.

For further information please visit: http://www.nhscarerecords.nhs.uk/ or Phone 0300 123 3020

Care and Health Information Exchange (previously Hampshire Health Record (HHR)

The Care and Health Information Exchange was previously the HHR, it has been running since 2005, and provides a shared health record for patients resident in Hampshire, Southampton and Portsmouth. It combines an extract of the GP record with hospital pathology/radiology reports and clinical correspondence and at present, there are GP records for 50% of Hampshire PCT patients. Winchester and North Hampshire Trusts will provide information shortly. The information is used by Out of Hours GPs, A&E clinical staff and admissions pharmacists to streamline and improve the management of patients in out of hours and emergency situations.

Access to the Hampshire Health record can only be made by staff who have the explicit consent of patients, and patients who do not wish to have a Hampshire Health Record may opt out.

For more information about how to view and/or withhold your record please go to www.careandhealthinformationexchange.org.uk

Research and the Clinical Research Network WESSEX

We may use some of this information for other reasons, for example, to help us to protect the health of the public generally, to plan for the future, to train staff and to carry out medical and other health research for the benefit of everyone.

Why do Research Here? Becoming a research active practice benefits everybody. It is recognised, that research helps develop better treatments and improves people’s health. It can also help the development and ultimately the service provided by the practice. There are lots of different research studies but they can be grouped into three types:

· Questionnaires - help us find out what would make a difference to a diagnosis or treatment

· Epidemiological - where a patient has agreed to share information held in their patient record to allow researchers to spot patterns which may help to understand illness and treatment

· Clinical trials - a patient agrees to participate in a trial to test how an intervention may help a patient and their treatment

These studies may be performed by academic researchers or commercial companies amongst others.

If anything to do with the research would require that you provide additional information about yourself, you will be contacted to see if you are willing to take part; you will not be identified in any published results. You can opt out at any time. This will not affect your care in any way.

For further information please visit the National Institute for health Research website at http://www.crn.nihr.ac.uk/can-help/patients-carers-public/

If you are contacted to participate in a research study you will be given the opportunity to opt out.

Future planning and research by wider NHS organisations

To opt out of your anonymised medical data being used to plan future services and for it not to be used to research new treatments, please visit www.nhs.uk/your-nhs-data-matters

Do I have a choice?

Yes. You have the right to prevent confidential information about you from being shared or used for any purpose other than providing your care, except in special circumstances.

If you are happy for your information to be used in this way you do not have to do anything.

If you do not want information that identifies you to be shared outside this Practice, please complete an opt out form which are available on our website or at our reception. This will prevent your confidential information being used other than where necessary by law.

Acting on behalf of others

If you are a carer and have a Lasting Power of Attorney for health and welfare then you can object on behalf of the patient who lacks capacity. If you do not hold a Lasting Power of Attorney then you can raise your specific concerns with the patient’s GP.

If you have parental responsibility and your child is not able to make an in-formed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is over the age of 16 then this must be their decision.

Do you wish to have a Summary Care Record? (N.B. this will mean that NHS Healthcare staff caring for you may not be aware of your current medications, any allergies or reactions to previous medication) *

Yes No

Do you wish to have a Care and health Information Exchange (CHIE), previously the Hampshire Health Care Record? wish to have a Care and Health Information Exchange record (previously Hampshire Health Record) (NB. Similar to Summary Care Record, just in the Hampshire Area) (NB. Similar to Summary Care Record, just in the Hampshire Area) *

Yes No

Do you wish to be contacted by our team about participating in clinical research studies? *

Yes No

If you do not wish for your medical data to be used by wider NHS organisations for future planning of services and researching of new treatments, please visit www.nhs.uk/your-nhs-data-matters

Next of Kin

Please give name, address, telephone number and relationship of next of kin (This information will only be used in case of an emergency) *

Will

Do you have a Do Not Attempt CPR or RESPECT form in place? If you do, please provide us with a copy. *

Yes No

Patient Accessible Information

If you require support accessing the Services at the Practice or require information to be sent to you in an alternative way,please speak to a member of our Patient Co-ordaintor team or email the Practice at nhccg.chawtonparksurgery@nhs.net

Do you have a visual / audio impairment? *

Signature

Signature *

Date *

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New Patient Questionnaire - 4

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