Student Patient Registration for UWE Bristol Health Centre

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

* Student Number (UWE Bristol Welcome ID):

* Title:

Mr Mrs Miss Ms

* Surname:

* First name:

Middle name(s):

Previous surname(s):

* Date of birth:

NHS No. (if known):

Please contact your previous surgery to get your NHS number.
Failure to do so will slow down your registration.

* Gender:

Male Female

* Town and country of birth:

Please fill in this section if you are going to stay in University Accommodation

Student Hall:
(university accommodation)
Flat:

Room:

Please fill in this section if you are not going to stay in University Accommodation

Address in Bristol:
(not university accommodation)

Flat number/House name
Street and number
Local area, eg. Filton

* Town:

* Postcode:

* UK mobile telephone number:

* E-mail address:

* Confirm e-mail address:

* May we contact you using email?

Yes No

Your GP would like to be able to communicate test results with you by SMS/text. Providing
your consent for this will allow us to let you know the results of important tests quickly.

* Do you consent to results being communicated to you by SMS/text? Yes No

NB: if you decline then you will also not receive appointment reminders.

	* Full name:
EMERGENCY CONTACT	* Phone no:
	* Relationship:

Nominated Pharmacy:

If you do not know your nearest and most convenient pharmacy here, please email the
surgery once you do and we can add this to your records (general.oldschool@nhs.net)
Until then it will default to The Old School Pharmacy in Fishponds.

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: (i.e. last address before going to UWE) * 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 student)

* Date when you arrived in UK:

Your first UK address where registered with a GP:
(only if you have previously registered with a GP)
Town:
Postcode:

If a previous resident in UK, date of leaving:

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 Immigration 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:

* Ethnic origin:		Other:
It is now a contractual requirement for GPs to record patients’ ethnicity information in their patient record if that person, or someone authorised on their behalf, chooses to share it. The information, which is optional and does not affect registration, should be recorded in coded form using the available categories, which include ‘prefer not to say’. Ethnicity information is sensitive personal data and must be processed and used only for medical purposes in accordance with data protection legislation. The GMS and PMS Regulations amendment is online.
Religion:
1^st language:		Need interpreter? Yes No

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

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

Please list any EXISTING OR PAST SIGNIFICANT MEDICAL CONDITIONS:

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

Please list any DRUG ALLERGIES
or ALLERGIC REACTIONS:

* Do you SMOKE? Yes No Used to smoke


* Amount you used to smoke per day:

* Amount you smoke per day:

For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818.

*Tick here to confirm that you have read the above

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

Reasonable Adjustment

Do you or your carer need any reasonable adjustment
to make your visit to the GP surgery accessible?
For example, an interpreter, wheelchair accessible
facilities or documents provided in accessible formats.

The information you provide about any disability, communication needs or reasonable adjustments
will be recorded in your GP record. It may be shared securely with other NHS services involved in
your care so they can make the adjustments you need. This helps us provide safe, accessible care.
If you have any questions about how this information is used or shared,
please speak to a member of the practice team.

* 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

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.

Blood Donation

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.
* = Compulsory.