Registration for the University of Lincoln Health Service

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.

Name of course (if relevent):

* Title:

Mr Mrs Miss Ms

* Family Surname:

* All first names:

Previous surname/s:

* Date of birth:

NHS Number (if known):

* Gender:

Male Female

* Town and country of birth:

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

House/Hall in Lincoln:

Flat/Block/House:

Room:

* or; Type in your new Lincoln address below if you are not staying in University accommodation.
Please include block and flat 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/yy):

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

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/yy):

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
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:

For help with stopping smoking, visit http://www.quit51.co.uk/ or text QUIT to 66777
In addition, the number for the local smoking cessation helpline is 0800 622 6968
* Tick here to confirm that you have read the above

ALCOHOL

* How often do you have a drink containing 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

IMMUNISATIONS

If known, please complete your vaccination dates for:

MMR 1st dose:

MMR 2nd dose:

Meningitis ACWY:

ETHNICITY
* ETHNIC GROUP:		Other:
Your first language:

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 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 do NOT agree to opt in

VitruCare (Lincoln University Students Only)

VitruCare is a digital platform to help you manage your health and wellbeing, which can be accessed through your smartphone, tablet or laptop. This platform can be used on your mobile devices, laptops and tablets and will support you to maintain good health and wellbeing with access to Student Wellbeing Services, the GP Practice, chatbot and the 24/7 Mental Health Helpline all from your own device.

This platform is a digital offer and will run alongside any intervention you have with University Services.

Click here for further information: University of Lincoln VitruCare Platform.

* Do you consent to having access to the VitruCare digital platform?

Yes No I am not a student

We might CONTACT YOU via text message or email unless you don't want us to:

Do NOT contact me by text
Do NOT contact me by email

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

	Deaf interpreter		Longer appointments
	Language interpreter	Other:

FEMALES over 25

Do you wish to attend for cervical screening? 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, alternatively you can fill out the form below.

I would like to join the NHS Blood Donor Register as someone
who may be contacted and would be prepared to donate blood:

Tick here if you have given blood in the last 3 years:

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.