Registration for Student Health
at Sheffield Hallam University

It's very important that you register with a GP practice in Sheffield if you're
coming to live and study here. Once registered at a GP practice they can:

Get hold of your medical history as soon as possible
Send information to you on relevant health issues
Pick up on any ongoing medical problems
Sort out any prescriptions you need to request

But most importantly, it will be the place you know to go
when you are ill, and the place they know about you!

If you're moving to Sheffield, we advice you to register with our medical centre. If you're staying at home and commuting into the university you can choose to register with us or stay with your own GP surgery. For convenience we do provide flexible appointments to fit around your studies.

This registration form should only be used by Sheffield Hallam University Students.

Please do NOT use this form to update your address or contact details.
Phone the practice (0114 225 2134) or go to the website to update your address or contact details.

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 Student Health Service to do so.

* Have you ever registered
with this practice before?

Yes No

Student ID:

* Course title:

* Course start:

* Course Length:

(dd/mm/yy)

* Title:

Mr Mrs Miss Ms Other

* Family name/Surname:

* All first names:

Known as name:

Previous surname/s:

* Date of birth:

NHS Number:

Please contact your previous surgery
to get your NHS number. Failure to do
so can slow down your registration.

* Gender:

Male Female Other

Marital status:

Single Married

* Town and country of birth:

ADDRESS in Sheffield

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

Students Accommodation in Sheffield:

or; type in your new address at University below .
Please include block and flat number if applicable so that we can contact you!

Block/Flat/Room:
House:
* Street:
* Town:
* Postcode:

* Mobile phone number:

* Email address:

* Confirm email address:

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

* Are you an ARMED FORCES VETERAN? Yes No

Please tick here if you DON'T wish for us to PROCESS YOUR REGISTRATION prior to arrival:
You are registered with your current GP until we process your registration.

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)

IHS ReferenceNumber:

Biometric Residence Permit number:

* 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...

* Signature:

Clear

Health Questionnaire

We are looking forward to welcoming you as a patient to Student Health at Sheffield Hallam University. To make this
as smooth a process for you as possible, it would be really helpful if you could answer the following questions.

EMERGENCY CONTACT DETAILS
Who would you like us to contact if there is a medical emergency?
Name: Telephone: Your Relationship:

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?

Meningitis ACWY:	Yes	No	Not sure
1^st MMR vaccine:	Yes	No	Not sure
2^nd MMR vaccine:	Yes	No	Not sure
Are you planning to have these before you arrive at university?	Yes	No
(if Yes please bring documentary evidence to the medical centre)

HEIGHT:

WEIGHT:

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 a MENTAL HEALTH CONDITION for which you
take medication or regularly see a GP or psychiatrist for?

Yes No

* Do you have any ongoing MEDICAL CONDITIONS for which you see a hospital consultant or a GP regularly
(e.g. arthritis, inflammatory bowel disease, asthma, epilepsy, skin conditions, contraception) or repeat medication?

Yes No

* Have you got SICKLE CELL disease? Yes No

Please give details of any ALLERGIES
to MEDICINES you have:

SMOKING
* Do you smoke? Yes No Used to smoke


What did you smoke? Pipe: Cigars: Own rolled cigarettes: Purchased cigarettes:
Amount you smoked per day:
* Date you stopped smoking:

What do you smoke? Pipe: Cigars: Own rolled cigarettes: Purchased cigarettes:
* Amount you smoke per day:

For help with stopping smoking, visit http://sheffield.yorkshiresmokefree.nhs.uk
The number for the local smoking cessation helpline is 0800 612 0011 or 0330 660 1166
* Tick here to confirm that you have read the above

ALCOHOL

* 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

* ETHNIC GROUP:		Other ethnicity:
Your first language:		Other language:
Interpreter required?	Yes No

* 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

Please provide a copy of your ID to the desk at the medical centre to complete your online access registration.
You will receive your user name and password via email.
If you wish to request access to your online medical record, please enquire at reception.

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 Student Health at SHU Privacy Notice.

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.

Registration for Student Health at Sheffield Hallam University

Registration for Student Health
at Sheffield Hallam University