Patient Health Questionnaire

If you would like to register with the practice please complete this health questionnaire.

To register a new patient you will need to live within our practice boundary.

As an existing patient you may also be asked to complete this form.

New Patient Health Questionnaire - Leckhampton

Patient Details

Please use date format DD/MM/YYYY
Are you happy to receive text messages? *
What is your gender? *

About you

Household Members

Are you a carer for a friend or relative? *
Are you cared for by a friend or relative? *

About your ethnic origin

I am: *

About your lifestyle

What is your smoking status? *
Please use date format DD/MM/YYYY
Are you interested in giving up smoking?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink that contains alcohol? *
How many standard alcoholic units do you have in a typical day when you are drinking? *
How often do you have six or more standard drinks on one occasion? *

About your medication history

Please list your regular medication:
Do you have any allergies? *
Are you allergic to Penicillin? *
Any adverse drug reaction? *

Immunisation History

Please use format DD/MM/YYYY

About your medical history

Please tick if you have any of the following long term conditions:

Women Only:

Have you had a hysterectomy? *
Are you pregnant? *

Sharing your health care records and information

The Summary Care Record and the sharing of basic information helps clinicians in A&E Departments and ‘Out of Hours’ health services to give you safe, timely and effective treatment.  Your patient record will be held securely on confidentially on our electronic system, and will only be accessed by authorised healthcare professionals directly involved in your care.  You will be asked if healthcare staff can look at your information every time they need to, unless it is an emergency and they are unable to; for instance if you are unconscious.

 With your permission, this information will be shared electronically via:

  •  SCR – NHS Summary Care Record (used nationally across England).
  • Gloucestershire Shared Health and Social Care Information (Joining up your information – JUYI) (Used locally across Gloucestershire)
  • Enhanced Data Sharing Model in SystmOne (EDSM) (Used nationally across all healthcare providers using SystmOne).

Your Summary Care Record contains basic information about:

  • Your current medications
  • Any allergies you have
  • Any bad reactions you have had to medicines

 **SCR with Additional information can be added upon request to your GP practice.  This includes:

  • Significant problems (past and present)
  • Significant procedures (past and present)
  • Anticipatory care information
  • End of life care information – as per EOLC dataset ISB 1580

JUYI contains information about:

  • Your current medications
  • Any allergies you have
  • Any bad reactions you have had to medicines
  • Your medical history and diagnoses
  • Test results and x-ray reports
  • Your vaccination history
  • General health readings such as blood pressure
  • Your appointments, hospital admissions, GP out-of-hours attendances and ambulance calls
  • Care / management plans
  • Correspondence such as referral letters and discharge summaries

Please note that these records are not connected with the Health and Social Care Information Centre care data project and will be used only for the purpose of enabling informed care to be supplied directly to you as an individual.

Parents, guardians or someone with power of attorney can ask for people in their care to be opted out, but ultimately it is the GP’s decision whether they share information, or not, because of their duty of care.

If you care caring for someone and feel that they are able to understand, then you should make the information about the different methods of sharing available to them.

Please tell us if you are happy for us to share this electronic information with clinicians in other NHS organisations (and Gloucestershire County Council social care in the case of JUYI) who are involved in your care.

Please read carefully and select one option for each question below:

Your Choice for the national SCR *
Your Choice for Gloucestershire shared health and social care information (JUYI) *
Enhanced Data Sharing Model (SystmOne) Sharing Out *
Enhanced Data Sharing Model (SystmOne) Sharing In *
If the person signing is not the patient, please give name and relationship to the patient.