NOTICE: Before you complete the form please use the postcode checker below to see if you are within our area. If you are within our area please choose a surgery and press next.
Please choose the location where you wish to be registered:
Petersfield Liphook Liss Next
Patient Details
* Star is to show which boxes must be completed.
Is your gender the same as assigned at birth?
Yes No
*Date of Birth (Day / Month / Year )
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 1 2 3 4 5 6 7 8 9 10 11 12 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
Address
Have you previously been registered with a Swan Surgery Medical Group Surgery?
Yes No If yes which surgery?
Swan Surgery, Petersfield Liphook Village Surgery Liphook Station Road Surgery Liss, Hillbrow Road Surgery Back Next
Medical Records
Please help us trace your previous medical records by providing the following information:
Your Previous address
Name of previous Doctor while at that address
Address of previous Doctor
Where did you last receive Treatment?
What was the outcome of this visit? ie prescription
If you are from abroad
Your first UK address when you registered with a GP
If previously a resident in UK you are REQUIRED to tell us the date you first came to the UK. Also, please tells us the date of leaving.
If you are returning from the Armed Forces
Address before enlisting
Are you a dependent of a family member currently serving in the armed forces?
Yes No If yes, are you a spouse or a child?
Spouse Child
Care Services
Please tell us about yourself
Are you a carer?
Yes No I the carer consent to my details being stored on the records of the person who is named as the patient on this form and subsequently the carers register.
Do you have a carer?
Yes No If yes, please tell us the name & address of your carer
Are you happy for us to contact your carer about you?
Yes No Are you or your children currently under the care of any external agencies/services eg Social Services. If so, please give details below:
In general, do you have any health problems that require you to limit your activities?
Yes No In general, do you have any health problems that require you to stay at home?
Yes No Do you regularly use a stick, walker or wheelchair to get about? (Please tick appropriate)
Stick for walking Uses zimmer frame Dependence on wheelchair In case of need, can you count on someone close to you?
Yes No Do you need someone to help you on a regular basis?
Yes No Back Next
Medical Information
Personal Medical History
Have you ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below:
Is the condition ongoing?Yes No
Is the condition ongoing?Yes No
Is the condition ongoing?Yes No
Do you have any disabilities?
Yes No If yes what are your disabilities?
Do you need any reasonable adjustments?
Yes No If yes what are the adjustments?
Family History
Have any close relatives (father, mother, sister, brother only) ever suffered from any of the following: (please indicate who in the boxes)
Heart Attack
Father Mother Brother Sister Stroke
Father Mother Brother Sister Diabetes
Father Mother Brother Sister High blood pressure
Father Mother Brother Sister Asthma
Father Mother Brother Sister Glaucoma
Father Mother Brother Sister Cancer
Father Mother Brother Sister Immunisations
State the nearest year in each box, if known.
Allergies
Please list any allergies you have to any drugs/medication.
Lifestyle
Please enter your height & weight.
Lifestyle Smoking
Do you smoke
Yes No If yes, do you smoke:
Cigarette Cigars Pipe Rolls own tobacco Electronic Cigarette Are you an ex-smoker?
Yes No When did you give up?
How many cigarettes/cigars do you smoke daily:
1 a day or less 1-9 a day 10-19 a day 20-30 a day more than 40 a day If you smoke a pipe how many ounces a week?
Would you like help to quit smoking?
Yes No If you are a smoker and would like help and advice on how to give up, please contact Quit4Life: 0845 602 4663 or go to www.quit4life.nhs.uk
Alchohol
Do you drink alcohol:
Yes No If yes, please answer the following question.
How many alcoholic units do you drink per week on average?(Units guide:Single spirit = 1 unit Small wine (125ml) = 1.5 units Pint beer = 2 units)
1-4 Units 5-10 Units 11-15 Units 16-20 Units 21 or more Units Lifestyle exercise
Do you exercise?
Yes No If yes, What exercise do you do? How often do you exercise?
Female patients only
Are you currently, or think you may be pregnant?
Yes No If you have any children how many?
Which method of contraception (if any) are you using at present?
If you have had a Coil fitted, what date:
Have you had a cervical smear test?
Yes No If yes, when was it and what was the result, if known?
Other Information
Ethnicity
Do you require an interpreter?
Yes No Next of kin
For Patients aged 65 and over
Do you hold a living will/
Yes No (Documentation regarding your personal wishes in respect of medical intervention at the time of serious illness, i.e. resuscitation etc)
Pharmacy Nomination
Pharmacy Address
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Data sharing consent choices
Care and Health Information Exchange (CHIE)
The Care and Health Information Exchange (CHIE) is a secure system which shares health and social care information from GP surgeries, hospitals, community and mental health, social services and others. CHIE helps professionals across Hampshire, the Isle of Wight and surrounding areas provide safer and faster treatment for you and your family by:
Ensuring that you only have to tell your story once
Reducing delays to your treatment. For example, by reducing the need to repeat blood tests
Making sure the doctors, nurses and others involved in your care know about your medical history
Identifying diseases that you might be at increased risk of developing in the future. This can help you take action early to protect your health
CHIE contains health and social care information from over 150 GP surgeries in and around Hampshire and the Isle of Wight, as well as local hospitals, community health, mental health and social care teams in order to help coordinate and improve your care. CHIE shows the medication you are currently taking, your allergies, test results and other important medical and care information. Health and care staff can see this information if they need to know about your previous history.
For more information please visit: www.careandhealthinforamtionexchange.org.uk
After reading the information above CAREFULLY please tick your choice below:
I would like to OPT IN to the CHIE Scheme
I would like to OPT OUT of the CHIE Scheme
Summary Care Record (SCR)
The Summary Care Record (SCR) is a national scheme and is used to support your emergency care nationwide. It will contain important information about medicines you are taking, any bad reactions or allergies to medications, your significant medical history and information about any long-term conditions. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly.
After reading the information above CAREFULLY please tick your choice below:
I would like to OPT IN to the SCR Scheme
I would like to OPT OUT of the SCR Scheme
In accordance with the Data Protection Act, we need your consent to carry out the following:
Send text reminders
Yes No Many people find it useful to have important messages sent to them via text messages. Here at The Swan Medical Group we can use texts to keep you informed about your appointments and if there are any issues or news about the practice.
Leave voicemail on mobile
Yes No Leave voicemail on landline
Yes No Leave voicemail on both
Yes No To make life a little easier we can leave messages on your phone either at home or on your mobile. You should be aware that your messages may be picked up by another person at home or if you don’t keep us informed of a number change.
DISCLAIMER – If you agree to the practice contacting you via your mobile phone or fixed landline number, we agree to adhere to the following;
1.The mobile number or fixed landline number will only be used by the practice and will not be passed to any other parties
2.If at any time you would like to opt out of either of the above services, please make a written request to the practice and you will be opted out of the service within 48 hours. You may also like to include your reason for opting out to help us review and improve the service in future
3.Your mobile phone number will solely be used by the practice in relation to the healthcare services offered by the practice. You will not be contacted in relation to any other types of products or services
Signature
I confirm that the information I have provided is true to the best of my knowledge.
Signature of patient Signature on behalf of patient
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