Friends and Family Test

Date

Please select the practice location most relevant to this Online Form submission

Patient details

Title*

First Names*

Surname*

Date of Birth*

Gender*

NHS Number

Birth Town*

Birth Country*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

Please help us trace your previous medical records by providing the following information

Have you previously been registered with an NHS GP in UK?*

Yes

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

Are you returning from the Armed Forces?*

Yes

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Family Member

Address and Postcode before enlisting

Service or Personnel Number

Enlistment date

If you are registering a child under 5

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

Already on it

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

Would you like to join the NHS Blood Donor Register?*

Yes

Already on it

Tick here if you have given blood in the last 3 years

I have given blood in the last 3 years

My preferred address for donation is:

Patient Health Questionnaire

Ethnicity*

Main language spoken:*

Are you cared for?

Yes

If yes, who is your carer?

Carer Name

Relationship to you

Carer contact number

Are you a carer?

Yes

If yes, who do you care for?

Relationship to you

Contact number

Health Information

Smoking status*

If you are a current smoker, how many do you smoke per day?

Have you been offered any stop smoking advice in the past year?

Height (cms/ft & ins)*

Weight (kg/stones & lbs)*

Waist measurement (approx cms/ins)

Exercise

Units:

Pint of regular beer/cider/lager - 2 units
Alcopop or can of beer/lager/cider - 1.5 units
Glass of wine (175ml) - 2 units
Single measure of spirts - 1 unit
Bottle of wine - 9 units

If your score (table 1 and 2 combined) is 5 points or more, please complete the Extended Alcohol questionnaire below.

Alcohol - Table 1

	1-2 drinks (0 points)	3-4 drinks (1 point)	5-6 drinks (2 points)	7-8 drinks (3 points)	9+ drinks (4 points)
How many standard alcohol drinks do you have on a typical day when you are drinking?

Alcohol - Table 2

	Never (0 points)	Less than Monthly (1 point)	Monthly (2 points)	Weekly (3 points)	Daily (or almost daily) (4 points)
How often do you have a drink that contains alcohol?
How often do you have 6 or more standard drinks on one occasion?

Extended Alcohol Questionnaire

Units:

Pint of regular beer/cider/lager - 2 units
Alcopop or can of beer/lager/cider - 1.5 units
Glass of wine (175ml) - 2 units
Single measure of spirts - 1 unit
Bottle of wine - 9 units

If your score above is 5 points or more, please complete the Extended Alcohol questionnaire below (tables 3 and 4).

Alcohol - Table 3

	1-2 drinks (0 points)	3-4 drinks (1 point)	5-6 drinks (2 points)	7-8 drinks (3 points)	9+ drinks (4 points)
How many standard alcohol drinks do you have on a typical day when you are drinking?

Alcohol - Table 4

	Never (0 points)	Less than Monthly (1 point)	Monthly (2 points)	Weekly (3 points)	Daily (4 points)
How often do you have a drink that contains alcohol?
How often do you have 6 or more standard drinks on one occasion?
How often in the last year have you found you were not able to stop drinking once you started?
How often in the last year have you failed to do what was expected of you because of drinking?
How often in the last year have you needed an alcoholic drink in the morning to get you going?
How often in the last year have you had a feeling of guilt or regret after drinking?
How often in the past year have you not been able to remember what happened when drinking the night before?
Have you or someone else been injured as a result of your drinking?
Has a friend/relative/Dr/health worker been concerned about your drinking or advised you to cut down?

Medical History

Do you have any known allergies?

Please indicate if you have ever suffered from any of the following:*

If yes to cancer, please specify

Family History

Please advise if any of your immediate family suffered from any of the conditions listed above in ‘Medical History’. Please state the condition and the relationship to you

Medication

Are you on regular medication? Please list drug name, strength and dose*

If no medications, please comment 'none'.

Immunisations

Diptheria

Tetanus

Polio

Typhoid

Hepatitis A

Hepatitis B

HIB

BCG

Men C

MMR

Flu

Pneumonia

Additional questions for female patients

Date of last cervical smear

Date of last mammogram

Date of last hysterectomy

Breast disease (date/details)

Contraception

HRT

Information for new patients: about your Summary Care Record

To help the staff involved in your care make better and safer decisions about how best to treat you.

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below; please indicate your choice on the form below.

a) Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.

b) Express consent for medication, allergies, adverse reactions and additional information.
You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

c) Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

Please note that it is not compulsory for you to complete this consent form. If you choose not to complete this form, a Summary Care Record containing information about your medication, allergies and adverse reactions and additional further medical information will be created for you as described in point b) above.

The sharing of this additional information during the pandemic period will assist healthcare professionals involved in your direct care and has been directed via the Control of Patient Information (COPI) Covid-19 – Notice under Regulation 3(4) of the Health Service Control of Patient Information Regulations 2002.

You are free to change your decision at any time by informing your GP practice.

Having read the above information regarding your choices, please choose one of the options below.

Yes - I would like a Summary Care Record

a. Express consent for medication, allergies and adverse reactions only

b. Express consent for medication, allergies, adverse reactions and additional information

No - I would not like a Summary Care Record

c. Express dissent for Summary Care Record (opt out)

Patient first name*

Patient Surname*

Date of Birth*

NHS Number (if known)

Address

Postcode

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

Date

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details (name) below:

Relationship to Patient

Parent

Legal Guardian

Lasting Power of Attorney

Identity Documentation

Please upload two forms of proof of identity. One photographic identity document and proof of address. Photographic identity documents are not required for child registrations.

Photographic ID - over 18

Drop files here or

Max. file size: 128 MB.

Driving licence, passport or Identity Card

Proof of address

Drop files here or

Max. file size: 128 MB.

Utility bill, council tax or bank statement

Online Access

I wish to be enrolled for Online Access (NHS App, SystmOne Online)*

Yes

I already have online access enabled

By ticking YES, you are consenting to be registered for Online Access to your medical record. You will receive by email or SMS your log in details.

Comments

This field is for validation purposes and should be left unchanged.

PLEASE READ PRIOR TO COMPLETION

The surgery is unable to provide any advice regarding COVID travel restrictions.
Before completing the travel questionnaire, please visit https://travelhealthpro.org.uk/ to check the vaccination requirements for your destination(s).
Travel advice and immunisations are offered, however please ensure that you book the appointment at least 6 weeks before you travel.
Please note that there is a charge for some of these vaccinations.
It is the travellers responsibility to check the entry requirements for their destination. Information can be found via the following link: https://www.gov.uk/foreign-travel-advice
Each individual traveller (including children) needs to complete a separate travel questionnaire form. We are unable to accept forms with multiple patient details.

Surname(Required)

First Name(Required)

NHS Number (if known)

Date of Birth(Required)

Address & Postcode(Required)

Contact Telephone Number(Required)

Travel Details

Overall length of trip (days/weeks/months)(Required)

Date of Departure(Required)

Country(s) to be visited and duration of stay in each place(Required)

Reason for Travel(Required)

Business

Pleasure

Visiting family or friends

Volunteer work

Other

Planned activities include:(Required)

Adventure

Diving

Safari

Trekking

Water sports

Other

I am staying in areas which are:(Required)

Urban

Rural

Altitude

I am travelling with:(Required)

Alone

In a group

With family/friends

The accommodation during my trip includes:(Required)

Backpacking

Camping

Cruise ship

Hostel

Hotel

Self-organised

Staying with family/friends

Any further information about your stay:(Required)

Medical History

Please list any recent or relevant medical history of note:(Required)

Please list any current medications:(Required)

Please list any allergies:(Required)

Do you have any history of mental illness, including depression or anxiety?(Required)

Yes

Don't know

Have you undergone radiotherapy, chemotherapy or steroid treatment in the last 2 years?(Required)

Yes

Don't know

Have you a history of a thymus disorder* or removal of the thymus gland (thymectomy) for any reason including incidental thymectomy (e.g. during cardiac surgery).

Yes

Don't know

Women only: Are you pregnant, planning pregnancy or breasfeeding?

Yes

Don't know

Do you or any close family members have epilepsy?(Required)

Yes

Don't know

Have you taken out travel insurance?(Required)

Yes

Don't know

If you have a medical condition, have you informed the insurance company?(Required)

Yes

Don't know

Vaccination History

Only tick if you know have previously received any of the following vaccinations or tablets(Required)

Have you ever had any previous problems or adverse reactions to vaccinations?(Required)

Yes

Don't know

Does having an injection make you feel faint?(Required)

Yes

Don't know

Have you had any live vaccinations in the last 4 weeks, or are planning to have?(Required)

Yes

Don't know

Name

This field is for validation purposes and should be left unchanged.

Church Street Surgery

Friends and Family Test

Church Street

Useful Links

NHS A-Z Conditions

Find Local Services

Live Well

Patient details

Please help us trace your previous medical records by providing the following information

If you are registering a child under 5

If you need a doctor to dispense medicines and appliances

Signatures

NHS Organ Donor Registration

NHS Blood Donor Registration

Patient Health Questionnaire

Health Information

Extended Alcohol Questionnaire

Medical History

Family History

Medication

Immunisations

Additional questions for female patients

Information for new patients: about your Summary Care Record

Identity Documentation

Online Access

PLEASE READ PRIOR TO COMPLETION

Travel Details

Medical History

Vaccination History

Church Street Surgery

Friends and Family Test

Church Street

Useful Links

NHS A-Z Conditions

Find Local Services

Live Well

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