University Health Service
Online Registration

CAN YOU REGISTER?

You can register with the University Health Service if you’re a:

1. University of Sheffield student living in Sheffield, or;

2. A dependant (spouse/partner/child only) of a student, and you live within our practice's inner boundary

See Who is eligible to register for more information.

This form makes up step two of registering with us. Make sure to complete step one as well otherwise your registration won't be finalised. See How to register with us for more information.

Please only complete this form once to avoid delays to your registration.

To check your registration status contact us at: syicb-sheffield.universityhealthservice@nhs.net

Current patients: DO NOT use this form to update your address or other details. Instead do this via the Change of details webform.

YOUR DETAILS

* First name(s):

* Surname (Family name):

* Date of birth:

NHS Number:

You can find your NHS Number using this link... You can also contact your previous surgery.
Failure to do so can slow down your registration.

* Biological sex:

* Email address:

* Confirm email address:

ABOUT YOU

* Your affiliation with the University of Sheffield:

* Student:

* Course end date:

i) International students: specify date you plan to leave the UK
ii) Dependents of students: specify the student’s course end date

* Have you lived in another country for 6+ months in the last 5 years?
Yes No
Which country?

* 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

HEALTH QUESTIONS

Note: Some questions are similar to step one of registration but this is to ensure we have the required level of detail.

IMMUNISATIONS

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 registering a CHILD aged 15 or under, please enter their childhood immunisations (including dates):

CONDITIONS

* 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:
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:

SMOKING

* 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)

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

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:

INFORMATION

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 thecourse 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. See Confidentiality for more information.

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. See Organ donation for more information.

Blood Donation

See Blood donation for information about becoming a blood donor.

Please read our Privacy Notice.

* = Compulsory.

University Health Service Online Registration

University Health Service
Online Registration