The Health Centre at the University of Sussex

Online 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 Health Centre to do so. If you are unsure
of your registration status, you can contact the practice who will be able to confirm this for you.

Current patients: DO NOT use this form to update your address or other details.

* Have you registered with the NHS before?

Yes No

* Have you registered with this practice before?

Yes No

* Are you a student?

Yes No

* 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...

* Marital status:

* Sexual orientation:

Other:

* Religion/Belief:

Other:

* Place of birth:

* Town: * Country:

Please select your student accommodation OR fill in your new Address in Brighton:

Student Accommodation:

Flat/Room:

House/Hall:

* Street Address:

Area:

* Town:

* Postcode:

* Email address:

* Confirm Email address:

* UK Mobile telephone number:

* May we contact you using email?

Yes No

* May we contact you using SMS text?

Yes No

	* Full name:
Emergency Contact	* Phone no:
	* Relationship:

Is your Emergency Contact also your Next of kin? Yes No

Do you give permission to discuss your medical records with them? 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 are from UK or abroad:

from UK
International

Part 2: Fill in if you come from 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:

I certify that the information I have provided is correct and consent
to my personal and medical information being used as stated.

* Signature:

Clear

Health Questionnaire

* Ethnic origin:	Other:
* First language:	Do you speak English?	Yes No
	Do you read English?	Yes No

Are you a carer?

Yes No

Do you have a carer?

Yes No

* Height:

* Weight:

* Do you SMOKE? Yes No Used to smoke

* Amount you used to smoke per day:

When did you stop?

* Amount you smoke per day:
Are you interested in advice on how to quit?	Yes No

Please state how much EXERCISE and
what type of exercise you do per week:

* 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

IMMUNISATION HISTORY

Please list any immunisations/vaccinations
you have had and the dates you had them:

* Have you been diagnosed with any of the following CONDITIONS? Please enter onset date.
Diabetes:		Eating disorder:
Epilepsy:		Mental health issue:
Hypothyroidism:		Coronary Heart Disease (CHD):
Hypertension:		Congenital Heart Disease:
Inflammatory bowel disease:		Cancer:
Asthma:		ADHD:
		For more information regarding the prescribing of ADHD medication in general practice, please read this.
I have used an inhaler within the last 18 months: I use an inhaler 3 or more times per week:
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:

Do you suffer from any ALLERGIES?Yes No

* Please specify what you are allergic to, what happens and when you had your first reaction:

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

* Please list any prescribed medicines you use:

EYE SIGHT:

Good Poor Registered Blind

HEARING:

Good Poor Partially Deaf Deaf

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:

* 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

Named Accountable GP

The department of Health has advised that all patients of 75 years and older have a named and
accountable GP to oversee their care. Please ask the name of the GP assigned tooversee
your care. Please note that this does not prevent you from seeing the GP of your choice.

Electronic Prescriptions (EPSs)

If you are on repeat medication and would like this sent direct to a pharmacy of your choosing when requesting it, you can sign up by going into your chosen pharmacy and asking them to sign up for the 'EPS Service'. Alternatively, you can ask us at Reception in the Health Centre.

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Organ Donation

Organ donation in England has changed to an 'opt out' system. You still have a choice
about whether or not you wish to become a donor and your faith, beliefs and culture will
continue to be respected. You can record your organ donation decision on the
NHS Organ Donor Register. Tell your family and friends what you have decided.

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.

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.