Date Received
BUSHLOE SURGERY
New Patient Registration Form
Thank you for choosing Bushloe Surgery.
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For Patients aged 16 and over: Please complete all forms IN FULL and bring back to the surgery
along with photographic proof of ID (ie passport or driving licence), proof of address (mobile phone bill
cannot be accepted) and a urine sample.
For Patients aged 15 and under: Please exclude the Lifestyle section of this form and complete the
Community Health Services – Children’s Health Visiting and School Nurse Liaison form (one per family)
All completed forms and accompanying items must be brought into the surgery before 12 noon.
Completed forms cannot be accepted without all of the accompanying items.
The information provided with this form will form part of your medical record.
PERSONAL DETAILS
Full Name
Telephone Number
Mr/Mrs/Miss/Ms/Other
Work Number
Address and Postcode
Mobile Number
E-mail Address
Next of Kin
Relation to you
Next of Kin Contact Number
Date of Birth
Maiden Name/ Previous Surname
Marital Status
Height
Gender
Feet/inches
cm
Weight
Blood Pressure Reading 1 (Please use the machine in the porch at the
Male
Female
Stones/lbs
kg
Blood Pressure Reading 2
surgery. Take 2 readings ,5 minutes apart)
HEALTH
Do you suffer from any of the
following conditions ?
(tick all that apply)
Asthma
Type 1 Diabetes
Type 2 Diabetes
COPD
Heart Disease
Hypothyroidism
Hypertension
Cancer
What operations have you had and
when?
Do you have any medical problems
at present?
Please attach your repeat medication list from your prescription or bring your
medicines with you when you bring this form back.
Do you take any regular
medications?
Nominated Chemist
We will send your prescriptions to your nominated
chemist via the Electronic Prescription Service
Do you have any known allergies?
Women Only
When was your last smear done?
Date of last mammogram
(if applicable)
Date
Result (if known)
Date
Result (if known)
FAMILY HISTORY
Do you have a family history
(close family member) of any
of the following conditions?
Insert relation to you in relevant box(es)
Heart Disease >60
Heart Disease <60
TIA/Stroke
Diabetes
Asthma
High Blood Pressure
Cancer
Any Other
LIFESTYLE
Details of person cared for
If you are a carer, please provide the details of the
person you care for
Details of carer
If you have a carer, please provide their details and
sign here if you wish us to disclose information about
your health to them
Signed
Current Smoker
Do you smoke?
Date
Ex-Smoker
Never Smoked
(please tick 1 box only)
Yes
If current smoker are you interested in stopping? (please tick)
No
Never
Monthly or less
(please tick 1 box only)
2-3 times per week
4+ times per week
How many standard* alcoholic drinks do you
have on a typical day when you are drinking?
1-2 drinks
3-4 drinks
(please tick 1 box only)
7-9 drinks
10+ drinks
Never
Less than monthly
Weekly
Daily or almost daily
2-4 times per month
How often do you have an alcoholic drink?
How often do you have 6 (females) or 8
(males) or more, standard* alcoholic drinks
on one occasion?
5-6 drinks
Monthly
(please tick 1 box only)
* A standard alcoholic drink is 1 unit of alcohol – a small glass of wine, a pub measure of spirits or ½ pint of lager/beer
SUMMARY CARE RECORDS
The NHS are changing the way your health information is stored and managed. The NHS Summary Care Record is an
electronic record of important information about your health. Please see the enclosed leaflet.
Yes
Are you happy to have a Summary Care Record?
No
PATIENT PARTICIPATION GROUP
The practice is committed to improving the services we provide to our patients. To do this it is vital that we hear from people
about their experiences, views and ideas for making services better. By expressing your interest you will be helping us to
plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views
and up to date with developments within the practice. If you are interested in getting involved please tick the box below and
we will be in touch.
Yes
Yes I am interested in becoming involved in the Practice Participation Group?
ETHNIC ORIGIN
White British
White Irish
White & Asian
Indian
Black African
Somalian
(Please tick 1 box only)
White & Black African
Pakistani
White & Black
Caribbean
Bangladeshi
Chinese
Middle Eastern
Other (please write in)
Signature of patient/parent/guardian
Black Caribbean
Date
For Office Use Only
Patients 16 +
Patients <15
GMS1
Reg Form
ID
GMS1
Reg Form
HV&SNL Form
Received By
Address
Urine
BP
Proetin
Nitrites
Ketones
Date
Notes for Surgery
Urine Sample
Blood
Glucose
Leucocytes