Student Patient Registration

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

* University:

Studying subject:

Year you started at this university:

* Year due to finish at this university:

* Title:

Mr Mrs Miss Ms

* Surname:

* First name(s):

Previous surname(s):

* Date of birth:

NHS No. (if known):

* Gender:

Male Female Other

* Town and country of birth:

Please select or fill in your ADDRESS in Newcastle:

University accommodation:

Room/Flat/Studio:

* Street:

Area:

* Town:

* Postcode:

* Mobile telephone number:

	* Name:
EMERGENCY CONTACT	* Phone no:
	* Relationship:

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 university) * 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:

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...

* E-mail address:

* Confirm e-mail address:

* Signature:

Clear

Health Questionnaire

* Height:

* Weight:

Physical Activities and Eating Habits:
Which best describes your normal exercise pattern per week?
Which best describes your normal eating pattern?

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

Are you a carer?

Yes No

Do you have a carer?

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:

Please list any other existing or past SIGNIFICANT MEDICAL CONDITIONS including major operations and dates:
Please list any CURRENT MEDICATION, including inhalers and contraception. Please specify dose:
Please list any significant FAMILY HISTORY of illness:
Please list any DRUG ALLERGIES or ALLERGIC REACTIONS:

WOMEN OVER 25: Have you ever had a smear test? Yes No
Date:	Where:	Result:
If you are over 25 and have not yet had a smear please make an appointment with the Practice Nurse.

Have you had HPV VACCINATION? Yes No
Indicate vaccine (if known): Cervarix Gardasil
First date:	Second date:	Third date:

* 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 or Special Communication Needs? 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

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.