New Patient Registration/Health Questionnaire - Pontllanfraith Health Centre

All information supplied will be recorded in your confidential medical records.

Contact Details

Gender

Marital status

Ethnicity

Home phone number

Work phone number

Mobile number (if aged 16 or over)

Language preference

English
Welsh
Other

If Other, please specify

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccinations reminders and anything else relevant to your healthcare?

Yes

We have an electronic method of contact available for patients to contact the surgery for non urgent requests - do you consent for us to correspond with you via this method and supply us with a preferred email address for this purpose?

Yes

Email address

Yes

Smoking

Do you smoke?

Yes
No
Ex-smoker

If yes, how many (Cigarettes per day, ounces of tobacco per day, Electronic cigarettes)

If ex-smoker, what date did you stop smoking?

Alcohol

For the following questions please answer to the best of your knowledge.

We have provided a basic guide to alcohol content below to assist your completion.

A 750ml bottle of wine contains 10 units.

A standard(175ml) glass of wine contains 2 units.

A single small shot of spirits (25ml) contains 1 unit.

A standard 70cl bottle of spirits contains 28 units.

A pint of 3.6% strength lager/beer/cider contains 2 units.

A pint of 5.2% strength lager/beer/cider contains 3 units.

How many units of alcohol do you drink a week?

Height & Weight - Please tell us your most recent measurements for the following (if known).

Height

Weight

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

Next of Kin

Name

Relation

Contact number

Family History

The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?

Heart Disease?

Yes

Stroke?

Yes

Cancer?

Yes

Medication

Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.

Yes

Name of drug - Dosage

Please add a photo of your most recent repeat medication slip if you have one.

Allergies

Do you have any allergies?

Yes

If Yes, please give details

Past Medical History

Please give details of any treatments/medical conditions.

Carer Information

Do you need / have anyone who looks after you or your daily needs as a Carer?

Yes

If Yes, would you like them to deal with your health affairs here?

Yes

Do you care for anyone else?

Yes

History

Have you been registered here previously?

Yes

Have you moved to the UK from abroad?

Yes

Special Circumstances

Military Veteran

Have you ever served in the Armed Forces?

Yes

Communication

Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?

We now need you to provide proof of your identification and your address. We ask for 2 things:

Step 1

A photo of your passport or driving licence, as proof of your name;

Step 2

A photo of a recent utility bill or similar, from sometime over the past 3 months, as proof of your current address. Please note that we use these items once for verification when setting up your account, and we delete them as soon as your account is open.

Proof of ID - e.g. your passport or driving licence

Proof of your address - e.g. a recent utility bill

ACCEPTABLE BEHAVIOUR CONTRACT

Dr Waheed & Partners at Pontllanfraith Health Centre, we are committed to promoting access to our services and offering choice wherever possible in the services we provide, and the way we deliver them. An acceptable behaviour contract is an individual written agreement between a patient and their GP Practice.

The contract is between you and Dr Waheed & Partners, Pontllanfraith Health Centre and is valid from the date of application to register as a patient at the surgery.

I agree to the following: 1. I agree to attend all appointments on time and/or cancel any appointments I am unable to attend, giving as much notice as possible. 2. I agree to the Pontllanfraith Health Centre DNA (Did Not Attend) policy - if after I have missed 2 appointments without notifying the surgery I will be removed from the practice list and will have to register with a different practice. 3. I agree to adhere to the Pontllanfraith Health Centre repeat prescription policy and agree to allow 2 working days before collecting my repeat prescription. 4. I agree to treat Dr Waheed & Partners and their staff, fellow patients and their carers and visitors politely and with respect at all times. 5. I agree to not smoke, consume alcohol and/or take non-prescribed medication or drugs whilst on NHS premises. 6. I agree to refrain from using abusive or offensive language, making threats of violence or aggressive behaviour and to treat all staff fairly and with respect; in person, on the phone, in writing or on social media. 7. I accept and understand that Dr Waheed & Partners are obliged to provide a safe and secure environment for its entire staff and care for their health and safety, and I accept and understand that no member of staff must jeopardise their own safety in providing me care. Page 2 of 2 (Reviewed August 2022 – To be re-reviewed August 2023) Breach of this Contract: I understand that if I fail to adhere to the above conditions, I will be removed from the practice list. This contract serves as an initial warning in the event of breaches occurring. I accept that Dr Waheed & Partners and their staff will only restrict or withdraw my rights to care in exceptional circumstances, or if I have failed to comply with any of my responsibilities listed above. As a patient I accept that I can lose my right to receive mainstream NHS patient Care Services. When removal results from no. 6 above, any patients for whom this person is responsible ie. child or cared for individual and who live at the same address, will also be removed to avoid any risk of further abuse to clinicians undertaking home visits for said child or cared-for individual

Have a duty of care to you as patient, and aim to provide appropriate and effective healthcare services and treatment to you, to meet your needs at all times. • Aim to provide healthcare services that are sympathetic to my individual needs within the resources which the Aneurin Bevan Health Board (ABHB)/Primary Care Contractor has available. • Treat you with courtesy and respect, and ensure you are dealt with quickly, fairly and in a helpful manner. • Ensure that staff take responsibility for resolving or dealing with your query, and/or that they refer to an appropriate colleague.

Do you agree to the above

Yes