Student Patient Registration for Bradford Student Health Service

Please fill in your details and click Submit when complete. * = compulsory

Please only complete this registration form once. If you have previously submitted this form
at any time please do not do so again unless advised by the Student Health Service to do so.
Please do not use this form to update your address or other details.

* Title:		Mr   Mrs   Miss   Ms
* Surname:
* All first names:
Previous surname/s:
* Date of birth:		Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916
NHS No. (if known):
* Gender:		Male Female
* Town and country of birth:
* Select your new University address from the list below if you are staying in University accommodation
Address in Bradford: Appartment/Flat No.: Room No.:		Select House/Hall House/Hall not allocated Crispin Edda Goldfinch Heron Humbolt Merryweather Moorpark Morello Peregrine Ribston Pippin Roundell Valor Vranga Willingham All Saints Hall Arkwright Hall Bradford Hall Charles Morris Hall Dennis Bellamy Hall Doris Birdsall Hall Forster Hall International House Kexgill House Revis Barber Hall Trinity A Hall Trinity B Hall Trinity C Hall University Hall School of Management Vernon Barnby Hall Wardley House
* or; Type in your new University address below if you are not staying in University accommodation
House Number: House Name: * Road or Street: * Town: * Postcode:
* Mobile telephone number:
* Can we contact you by SMS (text)?		Yes   No
* E-mail address:
Please help us trace your medical records by selecting if you are a UK or International student (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:		UK Student International Student
Part 2: Fill in if you come from the UK Previous address in UK before going to University House Number: House Name: * Road or Street: * Town: * Postcode: * Approximate date of first living at this address: Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 * Name of Doctor or Surgery when at that address: * Address of Doctor or Surgery: Postcode:
Part 2: Fill in if you come from abroad (international student) * Date when you arrived in UK (dd/mm/yy): * Expected date of leaving UK (dd/mm/yy): Your first UK address where registered with a GP: (only if you have previously registered with a GP) If a previous resident in UK, date you left (dd/mm/yy): Supplementary Questions: Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside of the European Economic Area must also have the status of 'Indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemption and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purpose of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. Please select one of the following options: More information... I understand that I may need to pay for NHS treatment outside of the GP practice I understand that I have a valid exemption for paying for NHS treatment outside of the GP Practice. I can provide documents to support this when requested This includes for example, an EHIC, or payment of the Immigratin Health Charge ("the Surcharge"), when accompanied by a valid visa. I do not know my chargeable status Complete the following section if you come from another EEA country: Do not complete this section if you have an EHIC issued by the UK. Do you have a non-UK EHIC or PRC? Yes   No Please enter details from your EHIC or PRC below: Country code: 3 Family Name: 4 Given names: 5 Date of Birth: (dd/mm/yyyy) 6 Personal Identification Number: 7 Identification Number of the Institution: 8 Identification number of the card: 9 Epiry Date: (dd/mm/yyyy) PRC validity period From: (dd/mm/yyyy) PRC validity period To: (dd/mm/yyyy) Tick here if you have an S1 (e.g. if you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. More information... How will your EHIC/PRC/S1 date be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purpose of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
* Signature:		Clear
Health Questionnaire
MEDICAL HISTORY – Please list all IMPORTANT illnesses you have suffered or may be suffering from, including operations and hospital admissions: Asthma          Diabetes          Mental Health Any other MEDICAL / SURGICAL / MENTAL HEALTH CONDITIONS  Please specify name of condition and year of diagnosis (if known): VACCINATION HISTORY Have you had an MMR vaccination? Yes   No
FAMILY HISTORY Is there a family history of any of the following before the age of 60? Heart disease     Stroke     Hypertension     Diabetes Please state any others you feel may be relevant:
MEDICATION Please list any MEDICATION you use regularly whether or not prescribed by your Doctor: * Please give details of any ALLERGIES  to MEDICINES you have: (answer None if you don't have any)
SMOKING * Do you smoke? Yes   No   Used to smoke
* Date you stopped smoking:     * Amount you smoke per day:     For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818. In addition, the number for the local Smoking cessation helpline is 01524 845145 * Tick here to confirm that you have read the above
ALCOHOL
* How often do you have a drink containing alcohol? Never Monthly or less 2-4 times / month 2-3 times / week 4+ times / week * How many units of alcohol do you drink in a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ * How often have you had 6 or more units (if female) or 8 or more (if male), on a single  occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily
EXERCISE How often do you do exercise which makes you breathless and increase your heart rate? * More or less than 5 thirty minute sessions per week?More   Less
* HEIGHT:	cm	* WEIGHT:	kg
Have you ever used/use Recreational DRUGS?		Yes   No
SCREENING QUESTIONS * During the last month, have you often been bothered by feeling down, depressed or hopeless? Yes   No * During the last month, have you often been bothered by having little interest or no pleasure in doing things? Yes   No   Over the last 2 weeks, how often have you been bothered by any of the following problems?   Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things: Feeling down, depressed or hopeless: Trouble falling or staying asleep, or sleeping too much: Feeling tired or having little energy: Poor appetite or overeating: Feeling bad about yourself – or that you are a failure or have let yourself or your family down: Trouble concentrating on things, such as reading the newspaper or watching television: Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual: Thoughts that you would be better off dead or of hurting yourself in some way:
*ETHNIC GROUP: Please select... British Irish Irish Traveller Traveller Gypsy/Romany Polish Any other White (please specify) White and Black Caribbean White and Black African White and Asian Any other Mixed (please specify) Indian Pakistani Bangladeshi Any other Asian (please specify) Caribbean African Somali Nigerian Any other Black (please specify) Chinese Filipino Any other ethnic group (please specify) Prefer not to say Other: Your first language:
IMPORTANT INFORMATION It is practice policy to share information that is recorded on your clinical record with other clinical staff that you are under the care of to ensure the best care is provided to you. For further information please ask for an information leaflet or visit www.nhscarerecords.nhs.uk/carerecords. * Please tick the box to confirm that you have read and understood this information:
Organ Donation Organ donation in England has changed to an 'opt out' system. You still have a choice about whether or not you wish to become a donor and your faith, beliefs and culture will continue to be respected. You can record your organ donation decision on the NHS Organ Donor Register. Tell your family and friends what you have decided.
Please read our Privacy Notice.

The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.