Registration Form GMS1 Step 1 of 2 50% TitleMrMrsMissMsMxDrOtherPlease specify:NHS Number: OptionalSurname:Prev Surname: OptionalFirst Names:Date of Birth Day Month Year Sex: Male Female Prefer not to say Other Please specify:Address Street Address Address Line 2 City Post code Town and Country of Birth:Ethnicity:White – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseFirst Spoken Language:Telephone NumberMobile NumberEmail Address Enter Email Confirm Email Please help us trace your previous medical records by providing the following information:Previous Address Street Address Optional Address Line 2 Optional City Optional Post Code Optional Name of Doctor while at that address OptionalAddress of previous doctor Street Address Optional Address Line 2 Optional City Optional Post code Optional Are you from abroad? Yes Optional No Optional Are you in the Armed Forces? Yes Optional No Optional If you are from abroad:Your first address where registered with a GP Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Optional If previously resident in UK, date of leaving Optional DD slash MM slash YYYY Date you first came to live in the UK Optional DD slash MM slash YYYY If you are from the Armed Forces:Address before enlisting Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Optional Service or Personnel number OptionalEnlistment date Optional DD slash MM slash YYYY Discharge date Optional DD slash MM slash YYYY If you need your doctor to dispense medicines and appliances:Not all doctors are authorised to dispense medicines. I live more than 1 mile in a straight line from the nearest chemist. Optional I would have serious difficulty in getting them from the chemist. Optional Carer DetailsAre you a Carer? Yes No Please give the details of the person you care for(Full name, Address, Contact Number)Do you have a Carer? Yes No Please give the details of your carer(Full name, Address, Contact Number)Emergency ContactName:Relationship: OptionalContact NumberAddress Street Address Address Line 2 City Post Code Next of KinNameRelationship to patientContact NumberAddress Street Address Address Line 2 City Post Code I have filled in this form on behalf ofMyselfMy childRelativeFriendOtherWould you like to have online access? Yes No If ‘Yes’ Please note, for online access, you will be required to provide photographic ID at reception to be granted access.Please confirm you agree to be contacted by SMS or email I agree to be contacted via SMS or email OptionalPreferred contact method SMS Email Please tick if you would like to have an NHS health check (16+ Only) I would like an NHS health check Optional NEW PATIENT QUESTIONNAIREPlease answer these questions to the best of your ability and hand this questionnaire into the receptionist. The information will be used to update your personal medical record.NameDate Of Birth Day Month Year Phone NumberEmail AddressHeightcmWeightkgWhat is your smoking status?Please selectCurrent SmokerEx SmokerNever SmokedHow many cigarettes do you smoke a day?When did you stop smoking? DD slash MM slash YYYY Do you drink Alcohol?Please selectYesNoHow often do you have a drink containing Alcohol?Please selectNeverMonthly2-4 times monthly2-3 time weekly4+ times weeklyHow many units do you drink on a typical day?Please select01-23-45-67-89+How often in the last year have you had 6 or more units (Female) or 8 or more units (Male) on a single occasion?NeverLess than monthlyMonthlyWeeklyDaily / almost dailyDo you have any allergies?Please selectYes – To a drug/MedicationYes -To something elseNoWhich Drugs/Medication? OptionalWhat are your allergies?Are you on any regular medication?Please selectYesNoWhat medication?Have you recently come to the U.K. from a country which has a high incidence of tuberculosis e.g. Lithuania or Romania?Please selectYesNoIf you have had a cough or any unexplained weight loss recently please make an appointment to see one of the doctors.From which Country? OptionalAre you a student?Please selectYesNoHave you had your MeningitusACWY vaccination?Please selectYesNoSUMMARY CARE RECORD – your emergency care summaryNHS England has introduced the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.GP practices are supporting Summary Care Records and as a patient you have a choice:Please selectYes I would like a Summary Care Record – you do not need to do anything and a Summary Care Record will be created for you.No I do not want a Summary Care Record – Please ask the receptionist for an opt-out form.For more information talk to the Patient Advice and Liaison Service (PALS), GP practice staff, visit the website www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.The Department of Health has asked us to record the ethnic origin, and first language, of all new patients. Please tick the box which most accurately describes you: White – British White – Irish Other White background White/Black Caribbean White/Black African White/Asian Other mixed background Chinese Indian/British Indian Pakistan/British Pakistan Bangladesh/British Bangladesh Other Asian background Caribbean/British Caribbean African/British African Other Black background Other ethnic background Prefer not to say What is your first main spoken language?Will you need a translator when you see one of our medical team?Please selectYesNoTHANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE
