Patient Registration for
Brownlow Health @ Princes Park

Please fill in your details and click Submit when complete.

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

IMPORTANT. Please note that Brownlow Health has multiple practices, so you need to
make sure that you are filling in the correct registration form for your chosen practice.
This form is for registering with 'Brownlow Health @ Princes Park'.
For details of the other practices, please click here.
* I have read and understand this:

* Please select one of the following:

	I live within the practice area (click here for practice area information)
	I live outside of the practice area, and would like to apply to be an ‘out of area’ patient

* Title:

Mr Mrs Miss Ms

* Family/Surname:

* First name(s):

Previous surname(s):

* Date of birth:

NHS No. (if known):

Contact your old surgery to get your NHS number.
Failure to do so will slow down your registration.

* Gender:

Male Female

* Town and country of birth:

University (if applicable):

Year due to finish university
(if applicable):

Please fill in this section if you live in University Accommodation

Address in Liverpool:
(university accommodation)
Room or Flat No:

Please fill in this section if you do not live in University Accommodation,
OR if your accommodation is not on the drop-down list above

Address in Liverpool:
(not university accommodation)

* Town:

* Postcode:

* E-mail address:

* Confirm E-mail address:

* Mobile telephone number:

We find that SMS/text messaging and email are often the most efficient methods of contacting patients about routine
matters e.g. to remind you of an appointment. We will never use text or email to send confidential medical information.

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

Please help us trace your medical records by selecting if you are from UK or
abroad (Part 1) and then filling in the next section (Part 2)

* Part 1. Select if you are from UK or abroad:

I'm from UK
I'm from abroad

Part 2: Fill in if you come from the UK
* Previous Address in UK: (i.e. last address before moving here) * Town: * Postcode:
* 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 patient)

* Date when you arrived in UK:

Study Visa expiry date:

Have you lived or studied in the UK before?

Yes No

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

	Full name:
EMERGENCY CONTACT	Phone no:
	Relationship:

Height:

Weight:

Think about all the moderate Physical Activities that you do in a typical week:
Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. This may include brisk walking, gardening, dancing, cycling, exercise and sport which last for at least 10 minutes.
On average, how many days per week do you do moderate physical activities?	Days per week
On those days, how much time did you usually spend doing moderate physical activity per day?	Minutes per day

Ethnic origin:	Other:
Religion:
1^st language:	Need interpreter:	Yes No
Occupation:

Are you a carer?

Yes No

Do you have a carer?

Yes No

Please tick if have, or have had, any of the following ILLNESSES:

Asthma:	COPD:	Heart problems:	High blood pressure:
Diabetes:	Stroke:	Thyroid problems:	Mental health problems:

Please list any other existing or past
SIGNIFICANT MEDICAL CONDITIONS
including major operations and dates:

Please list any CURRENT MEDICATION,
including inhalers. Please specify dose:

Please list any significant
FAMILY HISTORY of illness:

Please list any DRUG ALLERGIES
or ALLERGIC REACTIONS:

Have you ever been a member of the ARMED FORCES including the T.A.? Yes No

OVER 45: Have you had any broken bones since aged over 45? Yes No

WOMEN OVER 25: Have you ever had a smear test? Yes No	Please enter date:
All women over 25 should have a routine smear test and our reception team will invite you to make an appointment for this potentially lifesaving test. Please ask if you have any concerns.

Do you SMOKE? Yes No Used to smoke

Amount you used to smoke per day:

When did you stop?

Amount you smoke per day:

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 alcohol units per week do you drink?

NHS Alcohol Unit Calculator

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)

Scoring (add up score in brackets): 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence

Do you have a Disability? Yes No

Please describe your disability:
Please provide your preferred means of communication:
Text: Email: Sign Language: Hearing Loop: Other:
* Please note not all information is currently readily available *

Organ Donation

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

NHS Records

There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish.

NHS 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

ONLINE SERVICES

We offer online services so that you can have access to your medical record. If you would like online access to book/cancel appointments, order repeat prescriptions, amend your contact details, view your medical record and message the practice
please tick this box :
You will need to present at reception to verify your identity before access can be given.

How did you hear about us?

Other:

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.
* = Compulsory.

Patient Registration for Brownlow Health @ Princes Park

Patient Registration for
Brownlow Health @ Princes Park