Keele Practice New Patient Information

Transcription

1 ) )Dip/tetanus/polio )1 Keele Practice New Patient Infmation Name Todays date Male/Female University Address Uni tele: Mobile: Date of Birth Home Address address: Home tele: Significant Medical Histy Do you have any medical problems that you attend the hospital f? Family Medical Histy Current Medication ()including contraception( 目 前 服 药 包 括 避 孕 方 式 Immunisations( Allergies( 过 敏 免 疫 法 破 伤 风 小 儿 麻 痹 症 注 射 ) ( 麻 ( 疹 脑 膜 炎 C) booste/ / date [ ] Meningitis C date [ ] MMR st dose date [ ] 2 nd dose ( 滴 date 酒 不 [ 沾 )] Smoking Current smoker [ ] cigarettes/cigars number per day (please tick) Ex smoker [ ] Date stopped smoking. smoked [ ] If you smoke do you want to attend the stop smoking clinic Yes/ No Alcohol: Number of units per average week Teetotal [ ] Exercise: None [ ] Diet: Nmal [ ] (weekly) 1 Times [ ] Vegetarian [ ] 2 Times [ ] Other [ ]. 3 Times [ ] Are you a carer of do you care f someone else? (Please give details)

2 Country of Birth First Language Ethnic Origin: White- British [ ] White Irish [ ] White Other [ ] Chinese [ ] Asian Asian British Bangladeshi [ ] Asian Asian British Indian [ ] Asian Asian British Pakistani [ ] Asian Asian British Other [ ] Black Black British African [ Black Black British Caribbean [ ] Black Black British Other [ ] Mixed White & Black African [ ] Mixed White & Black Caribbean [ ] Mixed White & Asian [ ] Mixed Other [ ] Any other [ ] Date of cervical smear Please tick any specific needs that you have: Sensy impairment (hearing, sight etc) [ ] Physical disability [ ] Mental disability [ ] Religious/cultural needs [ ] Phobias [ ] Access to premises [ ] Dog assistance [ ] Advocacy [ ] F surgery use only Height Weight BP Other comments Alcohol Audit Results Sexual Health Sce 0-7 [ ] Health Advise [ ] Sce 8-15 [ ] Advised [ ] Condoms given [ ] Sce [ ] Advised [ ] Condoms refused [ ] Sce 20+ [ ] Referred to GP [ ] Screening advised [ ] Chlamydia test given [ ] Now please complete the alcohol audit below. This is based on a typical week not an exceptional week e.g. when you have been on holiday, attended an event and have drank me alcohol you nmally would have done. Following the alcohol audit there is a summary of how the practice may share some of your infmation, and an opt-out fm ( 出 生 日 if 期 you ) do not want to share your infmation. Please return the opt out fm with your registration fm if you wish to opt-out of anything so your medical recd can be updated. Alcohol Audit Name: DOB:

3 )after N.B. Only complete the following questions if your overall total sce from the above 3 questions is 5 me - 饮 酒 频 率 Scing system Your Questions sce 饮 酒 数 量 How often do you have a drink Monthly times times times containing alcohol? less per per per month week week How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 me 最 近 一 年 状 况 units if female, 8 me if male, on a single occasion in the? Questions you found that you were not able to stop drinking once you had started? you failed to do what was nmally expected from you because of your drinking? ( 懊 悔 you needed an alcoholic drink in the mning to get yourself going after a heavy drinking session? you had a feeling of guilt( 自 责 ) remse drinking? you been unable to remember what happened the night befe because you had been drinking? ( 评 分 ) Scing system but not Have you somebody else been No in the injured as a result of your drinking? ( 各 种 啤 酒 ) Has a relative friend, doct but not other health wker been concerned No in the about your drinking suggested that you cut down? I unit = 125ml wine, ½ pint of beer/lager/cider, 1 pub measure Your sce during the during the TOTAL

4 How we can help you control your personal and confidential infmation It is imptant that you know how your personal and confidential infmation may be used by the NHS and that you understand that you have the choice to opt-out of data sharing, if you wish. We have listed below the different types of NHS data sharing. If you wish to opt out of any all of the data sharing detailed below, please complete and sign the fm on the reverse of this sheet and hand it in at reception. We will then scan a copy of the fm onto your recds and add the appropriate code(s) to prevent data being shared. If you have already opted out there is no need to complete the fm. However, if you are not sure, please ask a member of the reception team. You are free to change your mind at any time. Leaflets regarding the types of data sharing are available at reception. 1. Summary Care Recd This is a national project and means that authised healthcare staff providing your care anywhere in England can access your Summary Care Recd. It contains infmation about any medicines you are taking and allergies reactions you have had to any medicines to ensure they have enough infmation to treat you safely. Healthcare staff will ask your permission befe looking at your Summary Care Recd. 2. Nth Staffs and S-O-T Shared Medical Recds If you attend the Accident and Emergency Department, Acute Medical Unit, Surgical Assessment Unit the Frail Elderly Assessment Unit at University Hospital of Nth Staffs, the Consultants/Docts there will be able to view some of your GP medical recd but only with your permission! The infmation that will be shared is your active and past problems, all of your medications (including repeat prescriptions), allergies, intolerances, adverse drug reactions, investigations and values, and vaccinations. You will be asked directly to give your explicit consent, at the point of contact, f your GP medical recd to be viewed. You can say YES NO. If you are unable to give consent, f example if you are unconscious, in extreme situations where you have refused permission and it is deemed to be vital f your survival, then a Consultant/Doct may still view your GP medical recd in der to be able to provide appropriate care f you. The Data Protection Act allows f this if it is in your interest. Your recd will only be viewed while you are being treated. This permission will throughout your treatment, up to a maximum of 24 hours. 3. Care.data/Data extracted under s251 of the NHS Act 2006 The NHS plan to use infmation about patients and the care they receive to help them plan and improve services f all patients. They want to link the infmation from all the different places where patients receive care, such as your GP, hospital and any community services, to help them provide a full picture. This will allow them to compare the care patients receive in one area against the care received in another, so they can see what has wked best. Infmation such as your postcode and NHS number will be used to link your recds in a secure system so that your identity is protected. F me infmation visit: call

5 Opt-Out Fm Title... Surname... First name (s)... Date of birth... Address Postcode... NHS number (if known)... Signature... Date... I wish to opt out of the following (please tick where appropriate) 1. Summary Care Recd 2. Nth Staffs and S-o-T Shared Medical Recds 3. Care.data and data extracted under s251 of the NHS Act 2006 (a) Opt out from data leaving the Practice (b) Opt out from data leaving the Health and Social Care Infmation Centre where they have collected infmation about me from other sources eg, the hospital Admin use only Opt-out coded (please circle) Opt-out Code: 1. Summary Care Recd 9Ndo 2. Nth Staffs and S-O-T Shared Medical Recds 93C1 3. Care.data and data extracted under s251 of the NHS Act 2006 (a) Opt out from data leaving the Practice 9Nu0 (0 is a zero) (b) Opt out from data leaving the HSCIC 9Nu4 Date coded:... Coded by:...