Registration for Rowhedge & University of Essex Medical Practice

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 Health Service to do so.
Please do not use this form to update your address or other details.

Have you ever registered with this practice before?

Yes No

Any student (+staff living on campus) can use this form to register.

Name of University Course and Department:

Duration of Course:

Years & Months

Non-EEA students studying on courses of 3 months' duration or less are not eligible to register.

* Title:

Mr Mrs Miss Ms

* Family Surname:

* All first names:

Known As first name:

Previous surname/s:

* Date of birth:

NHS Number (if known):

* Gender:

Other:

* Is this the gender you were assigned at birth?

Yes No

Sexual orientation:

Other:

* Town and country of birth:

* Select your new address from the list below if you are staying in University accommodation

House/Hall :

Floor/Block/House:

Flat:

Room:

(if applicable)

* or; Type in your new address below if you are not staying in University accommodation.
Please include flat and room number if applicable!

House Number:

House Name:

* Road:

* Town:

* Postcode:

Mobile phone number:

* Email address:

* Confirm email 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:

* Town:

* Postcode:

* Approximate date of first living at this address:

* 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/yyyy):

* Expected date of leaving UK (dd/mm/yyyy):

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/yyyy):

Supplementary Questions:

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

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...

* Signature:

Clear

Health Questionnaire

* HEIGHT:

* WEIGHT:

Current personal medical history
Have you currently any of the following?
High Blood Pressure		Thyroid Disease
Atrial Fibrillation		Chronic Kidney Disease
Heart Disease		Depression and anxiety
		Are you on medication?
Diabetes		Schizophrenia
Last HbA1c (if known):
Asthma		Bipolar affective disorder (Manic depression)
Peak flow (if known):
Epilepsy		Sickle cell disease
Date of last fit:

Past personal medical history
Have you ever had?
Cancer		Depression and anxiety
Stroke / TIA		Eating Disorder
Migraine		Psychosis/Serious Mental Health Problem

Family medical history
Has anyone in your family had?
Diabetes		High Blood Pressure
Heart attack before 60		Stroke before 60

Any other current and past MEDICAL /
SURGICAL / MENTAL HEALTH ISSUES
Please specify name of condition and
year of diagnosis (if known):

MEDICATION

Please list any precribed MEDICATION you use (including inhalers and creams) Please list name, strength and dose:

Please give details of any ALLERGIES to MEDICINES you have:

Are you a CARER?

Yes No

If yes, since when?

SMOKING
* Do you smoke? Yes No Used to smoke


* Date you stopped smoking:

* Amount you smoke per day:

Would you like help to stop smoking? Yes No

For help with stopping smoking, visit Essex Lifestyle Services
or call them on 0300 303 9988.
* Tick here to confirm that you have read the above

ALCOHOL

* How often do you have a drink that contains ALCOHOL?
Never	Monthly or less	2-4 times / month	2-3 times / week	4+ times / week

* How many standard alcoholic drinks do you have on a typical day when you are drinking?
1-2	3-4	5-6	7-9	10+

* How often do you have 6 or more standard drinks on one occasion?
Never	Less than monthly	Monthly	Weekly	Daily or almost daily

If your total alcohol score above is high it may indicate hazardous or harmful drinking. Please then complete the more detailed questions below (score in brackets):

How often during the last year have you found that you were not able to stop drinking once you had started?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

Have you or somebody else been injured as a result of your drinking?
No (0)	Yes, but not in the last year (2)		Yes, in the last year (4)

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No (0)	Yes, but not in the last year (2)		Yes, in the last year (4)

IMMUNISATIONS

If known, please complete your vaccination dates for:

MMR 1st dose:

MMR 2nd dose:

Meningitis ACWY:

ETHNICITY
* ETHNIC GROUP:		Other:
Your first language:

* Do you consent for us to discuss relevant information with the University Wellbeing Team,
should we be asked to do so?

Yes No

* Summary Care Records

Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take,
allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place
makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

I agree to opt in I do NOT agree to opt in

* Enhanced Data Sharing Model

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.
Do you consent for us to share your medical records with other medical service
you may be using i.e. District Nurse Teams, Podiatry or Dieticians?

I agree to opt in I do NOT agree to opt in

May we CONTACT YOU via text message or email?

You can receive communications from your GP Surgery by email and phone, however you have to give consent for this.
This includes; appointment reminders, test results, messages relating to your specific health need e.g. a flu
vaccination reminder, general health information that could benefit you, information about emergencies etc.
Your phone number/email address will not be provided to third parties.

* May we contact you by email?	Yes	No
* May we contact you by SMS/text?	Yes	No

Do you have any SPECIAL REQUIREMENTS when attending appointments
(please tick) or please advise of any other:

Hearing impairment Visual impairment Other:

FEMALES over 25

Do you wish to attend for cervical screening? Yes No

Have you ever had a Cervical Smear (PAP Test)? Yes No

Organ Donor Registration

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.

Blood Donor Registration

If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.

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.