University of Salford
Health Centre

Online Registration

* Are you a STUDENT or STAFF at the University of Salford (or will you soon be)?
Student Staff No

Course title:

Course Length:

* Title:
Mr Mrs Miss Ms

* All first names:

* Surname/Family name:

Previous surname:

* Date of birth:

NHS Number:

You can find your NHS Number using this link... You can also contact your previous surgery, but you do not need to know your NHS number in order to register with us.

* Birth Gender:

Male Female

* Gender identity:

Other:

Would you like to be known as the alternative Title of "MX", as opposed to your selection above?
Yes No

Marital status:

* Sexual orientation:

Other:

Religion/Belief:
Other:

* Town and country of birth:

ADDRESS when at University of Salford

If you are staying in University accommodation select your New University address from the list below.

Students Accommodation:

OR; type in your new address at University below. Please include block and flat number if applicable!
If your student address is outside of Manchester you may be asked by reception to complete an Out Of Area form.

Block/Flat/Room:

House:

* Street:

* Town:

* Postcode:

* Are you currently living at this address?
Yes No

If No, what date will you be moving to this address?

* Mobile number:

* Email address:

* Confirm email:

Do you give consent for us to CONTACT YOU via text message or email?
* Text/SMS:Yes No * Email:Yes No

You are giving permission for us to send you appointment reminders, information regarding your health care and clinic updates.

How would you prefer to be contacted?
Text/SMS Email

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/Name:

* Road:

* Town:

* Postcode:

* GP when at that address:

GP Practice Address:

GP Practice Postcode:

Part 2: Fill in if you come from abroad (international student)

* Date when you arrived in UK:

* Expected date of leaving 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...

Health Questionnaire

HEIGHT: cm

WEIGHT: kg

SMOKING
* Do you smoke or vape? Yes No Used to smoke

What did you smoke?
Pipe: Cigars: Own rolled cigarettes: Cigarettes: Vape:

Amount you smoked per day:

* Date you stopped smoking:

What do you smoke?
Pipe: Cigars: Own rolled cigarettes: Cigarettes: Vape:

* Amount you smoke per day:

For help with stopping smoking, visit This Link
The number for the local Stop Smoking Service is 0800 952 1000
* Tick here to confirm that you have read the above

Do you EXERCISE?

Avoid exercise

Light exercise

Moderate exercise

Heavy exercise

ALCOHOL

* 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?

* How often do you have 6 or more standard drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily/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	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never	Less than monthly	Monthly	Weekly	Daily or almost daily
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	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?
Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never	Less than monthly	Monthly	Weekly	Daily or almost daily
Have you or somebody else been injured as a result of your drinking?
No	Yes, but not in the last year		Yes, in the last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No	Yes, but not in the last year		Yes, in the last year

Your alcohol score is: 0
0 – 7: Lower risk, 8 – 15: Increasing risk, 16 – 19: Higher risk, 20+: Possible dependence

What's your DIET like?

Poor diet

Average diet

Good diet

Female patients over the age of 25 are eligible for CERVICAL SCREENING
Have you had a cervical screening? Yes No	What year?

IMMUNISATIONS

If you are attending university for the first time and are aged 24 and under, you should, if possible, ensure that you have received Meningitis ACWY and MMR (Measles, Mumps, Rubella) vaccines prior to commencing your studies.

Have you ever had the following vaccinations?

1^st MMR vaccine: Yes No

2^nd MMR vaccine: Yes No

Meningitis ACWY: Yes No

CARER

Do you look after a relative, friend or neighbour who cannot manage without your help due to sickness, age or disability?

Are you a carer? Yes No

Do you have any of the following MEDICAL CONDITIONS?

Asthma	Hypertension	Type 1 Diabetes
COPD	Epilepsy	Type 2 Diabetes
Cancer	IBS	Heart Disease

Have you ever been diagnosed with, or are you on a waiting list for any of the following (tick only which apply):

	ADHD		Autism
	An Eating Disorder		Gender Incongruence
	Anxiety, depression or other Mental Health problem
	Please tick this box if you've never discussed these with someone but would like to talk to us about one or more of them.

Any other current and past MEDICAL / SURGICAL / MENTAL HEALTH ISSUES
Please specify name of condition and year of diagnosis (if known):

Please list any MEDICATION you use regularly whether or not prescribed by your Doctor
(tablets, creams, inhalers, contraceptive etc):

Please give details of any ALLERGIES to MEDICINES you have:

Please give details of any DISABILITY:

Are you Registered BLIND or DEAF?
Registered blind: Registered deaf:

Please indicate if you require any of the following Communication Services:
British sign language: Text phone: Mini com: Large print: Lip reading:

MENTAL HEALTH

Do you consider yourself to be suffering from anxiety or low mood?
Yes No

EMERGENCY CONTACT DETAILS

Who would you like us to contact if there is a medical emergency?

Name:

Telephone:

Your Relationship:

Are you an ARMED FORCES VETERAN? Yes No

* ETHNIC GROUP:

Other ethnicity:

Your first language:

Interpreter required?
Yes No

Refugee or Asylum Seeker?

Country of origin:

* 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 agree to opt in I do NOT agree to opt in

* Important Information

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.
Your record will be automatically setup to be shared with the other Health Care organisations. These organisations will only be able to view your shared record if they are actually providing you with care. However, you have the right to ask your GP to disable this function or restrict access to specific elements of your record. This will mean that the information recorded by your GP will not be visible at any other care setting
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 agree to opt in I do NOT agree to opt in

ONLINE ACCESS REGISTRATION

Would you like to have access to the following online services?

Booking appointments: Yes No

Request repeat prescriptions:Yes No

* Signature:

Clear

Organ Donor Registration

If you are interested in becoming an organ donor, please click this link to go to the organ donor registration page.

Blood Donor Registration

If you are interested in becoming an blood donor, please click this link to go to the blood donor registration page.

Please read the CampusDoctor 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.

University of Salford Health Centre

Online Registration

University of Salford
Health Centre