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:		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):			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
Address in Bristol: (university accommodation)		Select first Brecon Court Mendip Court Cotswold Court Quantock Court Carroll Court Aspen House Beech House Chestnut House Hazel House Mulberry House Juniper House Laburnum House Poplar House Rowan House Sycamore House Walnut House The Hollies Wallscourt Park Flats Wallscourt Park Houses Select next
Please fill in this section if you are not going to stay in University Accommodation
Postcode: (fill in your new postcode and click Find Address)		Find Address
Address in Bristol: (not university accommodation)		Flat number/House name, eg. Flat 12/White House Street number and name, eg. 45 High Street Local area, eg. Filton
* Town:
* Postcode:
* UK mobile telephone number:
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.
* Emergency contact (full name and phone no.): * Relationship:
Nominated Pharmacy:		Please select... Stapleton Pharmacy (0.9 miles from UWE) Day Lewis Pharmacy (1 mile from UWE) The Old School Surgery Pharmacy (1.6 miles from UWE)
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: Day 1 2 3 4 5 6 7 8 9 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 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 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: Day 1 2 3 4 5 6 7 8 9 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 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
* E-mail address:
* Confirm e-mail address:
* Signature:		Clear
Health Questionnaire
Height:		Weight:
* Ethnic origin: 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: 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.
Please list any EXISTING OR PAST SIGNIFICANT MEDICAL CONDITIONS:
Please list any CURRENT MEDICATION, including inhalers. Please specify dose:
* 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. In addition, the Old School Pharmacy in Fishponds runs smoking cessation clinics, and can be contacted by phone on 0117 9651114 and by email at oldschoolpharmacy@nhs.net * 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
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.
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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.