GP Registration Form

	University of Central Lancashire Medical Centre Online Registration
By submitting this form you will be registered with UCLAN Medical Centre , which is a branch site of PSM Medical Group.
It's very important that you register with a local GP practice 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!
Please do NOT use this form 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 Medical Centre to do so.

* Have you ever registered
with this practice before?

Yes No

* Are you a STUDENT or STAFF at the University
of Central Lancashire (or will you soon be)?

Student Staff No

Course title:
Course end date:

* Title:

Mr Mrs Miss Ms

* Family name/Surname:

* All first names:

Previous surname/s:

* Date of birth:

NHS Number:

Find your NHS number...

* Gender assigned at birth:

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

* Sexual orientation:

Other:

Marital status:

Religion/Belief:

Other:

* Town and country of birth:

ADDRESS when at University of Central Lancashire

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

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 Preston 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?
By submitting this form you will be registered with the UCLan Medical Centre. If you need to be seen by a GP before you move to Preston you have to register temporarily with your usual GP.

* 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

* Your Nominated Pharmacy:

Other:
Find a pharmacy...

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:

* Name of GP Practice when at that address:

Address of 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...

* Signature:

Clear

Health Questionnaire

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
1^st MMR vaccine:	Yes	No
2^nd MMR vaccine:	Yes	No

HEIGHT:

WEIGHT:

Do you EXERCISE?
Avoids exercise		Light exercise		Moderate exercise		Heavy exercise


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

What's your DIET like?
Poor diet		Average diet		Good diet

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

Are you an ARMED FORCES VETERAN? Yes No

Do you have any of the following MEDICAL CONDITIONS? (Please tick and enter onset date)
	Asthma
	COPD
	Hypertension
	Type 1 Diabetes
	Type 2 Diabetes
	Epilepsy
	Eating Disorder
	ADHD
	ASD

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:

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 This Link
The number for the local Stop Smoking Service is 0800 328 6297
* 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

MENTAL HEALTH

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

* ETHNIC GROUP:	Other ethnicity:
Your first language:	Interpreter required?	Yes No
Are you currently a Refugee or Seeking Asylum in the UK?
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

Did you know that you can now access appointments, request prescriptions and view
your medical records online? You can arrange this by downloading the NHS App.
Visit https://www.nhsapp.service.nhs.uk/login to find out more.

Please let us know where you first heard about
the services provided by UCLan Medical Centre:

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 Central Lancashire Medical Centre Online Registration

University of Central Lancashire
Medical Centre
Online Registration