University Health Service
Online Registration

CAN YOU REGISTER?

To be eligible to register at the UniversityHealth Service you must be EITHER:

1. A student at The University of Sheffield living in Sheffield; OR

2. A dependent of a student at The University of Sheffield living within the Practice boundary

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 Health Service to do so. If you are unsure of your registration status, you
can contact the practice at syicb-sheffield.universityhealthservice@nhs.net who will be able to confirm this for you.

Current patients: DO NOT use this form to update your address or other details. This can be done via
email: contact syicb-sheffield.universityhealthservice@nhs.net, including your full name and date of birth.

From what date do you wish
to register at UHS from?

If you don't currently live in Sheffield, you should enter the date you expect to arrive in Sheffield.

Please note that if you already have a GP in the UK, your records will transfer to UHS from the date
given above.You will only be registered at UHS from the date specified above. If you no longer wish
to register on this date please email the Practice at syicb-sheffield.universityhealthservice@nhs.net

* Your affiliation with The
University of Sheffield:

Please note: proof may be required prior to fully accepting your registration

* Course end date:

* Title:

Mr Mrs Miss Ms

* Surname (Family name):

* First name(s):

Previous surname(s):

* Date of birth:

NHS No. (if known):

* Gender:

Male Female More information...

* Would you describe yourself as
Care-experienced?

Yes No I'd rather not say

* Would you describe yourself as being
Estranged from your family?

Yes No I'd rather not say

* Place of birth:

* Town: * Country:

Please select your student accommodation or fill in your new ADDRESS in Sheffield:

Student Accommodation:

Block/Flat/Room:

House/Hall:

* Street Address:

* Town:

* Postcode:

* Email address:

* Confirm Email address:

UK Mobile telephone number:

* I consent for the University Health Service to use my email address as described here: Yes No

* I consent for the University Health Service to use my phone number as described here: Yes No

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 have been registered with a GP before in the UK :

have previously had a GP in the UK
have never had a GP in the UK

Part 2: Fill in if you have previously had a GP in the UK
* Previous Address in UK: (i.e. the address your current GP will have for you) * Town: * Postcode:
* Name of Doctor or Surgery when at that address:
* Address of Doctor or Surgery: Postcode:

Part 2: Fill in if you have never had a GP in the UK (international student)

* Date when you arrived/will arrive in UK:

How many months will you stay in the UK?

Have you lived or studied in the UK before?

Yes No

Supplementary Questions THESE QUESTIONS ARE OPTIONAL

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

* Ethnic origin:	Other:
* Main language:	Need interpreter:	Yes No
* Have you lived in another country for 6+ months in the last 5 years?		Yes No
If yes, which country:

IMMUNISATIONS - essential information required

You are strongly advised by UHS to ensure that you are
fully immunised to UK Department of Health standards.

There is an increased risk of Meningitis, Measles, Mumps and Rubella due to the large numbers of students in the close
confines of a university campus, therefore it is important that you are vaccinated to protect both yourself and others.
Please indicate if you have/have not had the following:

* Meningitis ACWY vaccine:
	Yes, date:	Don't know when / No
* 1^st MMR (measles, mumps, rubella) vaccine:
	Yes, date:	Don't know when / No
* 2^nd MMR (measles, mumps, rubella) vaccine:
	Yes, date:	Don't know when / No

If this registration is for a CHILD aged 15 or
under, please enter his or her childhood
immunisations (including dates):

* Have you been diagnosed with any of the following CONDITIONS? Please enter onset date.
Diabetes:		Eating disorder:
Do you take insulin to control/treat your diabetes? Yes No
Epilepsy:		Mental health issue:
Thyroid disease:		Heart Condition:
Hypertension:		Organ transplant:
Cancer:		On blood thinners:
Asplenia:		Rheumatological condition:
Kidney disease:		Inflammatory bowel disease:
Liver disease:		HIV:
Asthma:		Thalassaemia/Sickle Cell Disease:
Only tick this box if you have had asthma symptoms and/or asthma medication in the past two years.
Which regular 'preventer' inhaler are you using? This is the inhaler that you use every day, NOT the blue salbutamol 'reliever' inhaler . Please record the name of the inhaler, the dose, how many puffs you use, and how often you are using it. For example: Clenil Modulite, 100 micrograms, 2 puffs, twice daily.
NONE of the above:

* Have you had/do you suffer from any OTHER serious illness
or condition not mentioned above?Yes No

* Please state if you have or have had any other significant medical condition. For each item please tell us the year the event happened or when the problem started:

* Have you had any significant INJURIES or OPERATIONS?Yes No

* Please state if you have or have had any significant injuries or operations . For each item please tell us the year the event happened:

* Do you have any DISABILITY/COMMUNICATION needs?Yes No

* Please state any disability or communication needs:

* Are you Allergic to any Drugs or Medication?Yes No

* Please state any drug or medical allergies you have (for example penicillin):

* Are you allergic to any Non-drugs?Yes No

* Please state any non-drug allergies you have (for example nickel or hay fever):

* Do you take any prescribed MEDICATION at present?Yes No
(including the pill and depo-injections)

* Please list any prescribed
medicines you use:

Patients are required to see a doctor for the first time a prescription for long-term medication is requested from us.
Make an appointment BEFORE your next repeat prescription is due. Thereafter, if it is
appropriate for you to receive repeat prescriptions the following points should be noted;

1. Request your repeat medication at least 1-2 weeks before you run out (in case an appointment is required)
2. It takes a maximum of 2 working days for repeat prescriptions to be processed
3. You will be required to see a doctor from time to time to review your condition and medication

* Your Height (in cm):

* Your Weight (in kg):

* Do you SMOKE? Yes Never Used to smoke (not now)

* Amount you smoke per day:

For help with stopping smoking, please visit the Yorkshire Smokefree Sheffield - website

or phone: 0800 612 0011 (FREE from landlines) / 0330 660 1166 (FREE from most mobiles).

* Tick here to confirm that you have read the above:

* Do you VAPE/use ELECTRONIC CIGARETTES? Yes Never Used to (not now)

* How often do you have a drink that contains ALCOHOL?
Never (0)	Monthly or less (1)	2-4 times / month (2)	2-3 times / week (3)	4+ times / week (4)

* 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 (0)	3-4 (1)	5-6 (2)	7-9 (3)	10+ (4)

* How often do you have 6 or more standard drinks on one occasion?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)


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)

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

If your score is 8 or more, your answers suggest you may be at increased risk of future harm to your health from drinking. Further information about this can be found at www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/how-much-is-too-much

* Tick here to confirm that you have read the above:

Next of Kin

Who you would like us to contact in the event of an emergency
Name:
Contact Number(s):

Are you a CARER?

Yes No

* Consent

Please confirm that you have read the information on our website regarding your Summary Care Record
and that you understand that you can opt out by completing the opt out form on our website?
We will assume your implied consent unless you contact the Practice and complete the opt out form:
Yes

Confidentiality & Data Sharing

The information that we hold on you at UHS is considered confidential. Your personal data is processed,
shared and stored in line with the requirements of the General Data Protection Regulations (GDPR). In the
course of everyday patient care and administration your data may be shared (in confidence) with specific
NHS organisations. Your medical records are held separately from your University records and will NOT
be shared with the University without your consent. For further information please visit our website.

Named Accountable GPs

From the 1st April 2015, all patients at the University Health Service will be given a named accountable GP.
They will be responsible for your overall care at the Practice. However, you will still be able to book
appointments with any doctor at the University Health Service that you choose.

Organ Donation

Organ donation in England has moved to an 'opt out' system. This means that all
adults in England will be considered to have agreed to be an organ donor when
they die unless they have recorded a decision not to donate or are in one of the
excluded groups. For further information: https://www.organdonation.nhs.uk/

Blood Donation

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

Please read our Privacy Notice.

* = Compulsory.

University Health Service Online Registration

University Health Service
Online Registration