Princess Street Surgery, Gorseinon, Swansea, SA4 4US

Tel: 01792 895681

Contact Details

FAMILY DOCTOR SERVICES REGISTRATION - GMS1

Your Details

Title: Surname: First names: Previous surname/s Home Address: Postcode: Town and country of birth: Telephone Number: Email Address: Date of Birth: NHS Number: Gender:

Please help us trace your previous medical records by providing the following information

Your previous address in UK: Name of previous GP practice while at that address: Address of previous GP Practice:

If you are from abroad

Your first UK address where registered with a GP: If previously resident in UK, date of leaving: Date you first came to live in UK:

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting:Postcode:Service or Personnel number:Enlistment date:Discharge date:

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

*Not all doctors are authorised to dispense medicines

NHS Individual Health Record Opt-Out

I want to opt-out of the Individual Health Record and prevent emergency care medical staff being able to access my key medical information. I have received enough information to make an informed decision and I acknowledge that opting out could be detrimental to my healthcare.

Further information is available by visiting the NHS Wales website or by calling NHS Direct on 0845 46 47.

Correspondence

Please tick this box if you wish to receive correspondence from us in Welsh.

Your Signature

You can provide a handwritten signature using touch or mouse. If you use a keyboard or assistive technology, please use the confirmation and typed name fields instead.

I confirm that the information I have provided is true and complete. If you are unable to provide a handwritten signature using touch or mouse, please type your full name below. This will be treated as your signature.

Language preference

English

Welsh

Other

If Other, please specify

Communication Consent

We have an electronic method of contact available for patients to contact the surgery for non urgent requests - do you consent for us to correspond with you via this method and supply us with a preferred email address for this purpose?

Yes

We offer an SMS service for appointment reminders, invitations, and feedback about your experience at our surgery. You may opt out at any time.

Yes – I consent to receive text messages from the surgery

No – I do not consent to receive text messages from the surgery

HEALTH QUESTIONNAIRE

What is your ethnic group?

Please select an option below that best describes your ethnic group or background:

White:

British

Irish

Irish Traveller

Traveller

Gypsy/Romany

Polish

Mixed:

White and Black Caribbean

White and Black African

White and Asian

Asian or Asian British:

Indian

Pakistani

Bangladeshi

Black or Black British:

Caribbean

African

Somali

Nigerian

Other ethnic group:

Chinese

Filipino

Other options:

Other (Enter below)

Not Stated

'Not Stated' should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to.

Any other background or other ethnic group (please enter if 'Other' selected):

Have you been a patient at the Surgery before?

Yes

If so what year?

Do you have any special communication needs?

Smoking habits

What are your smoking habits?

Smoker

Never Smoked

Ex-Smoker

Would you like support to quit smoking?

Yes

If a smoker, how many cigarettes/cigars etc. a day?

Date ceased (if an ex-smoker)

Alcohol Consumption

For the following questions please answer to the best of your knowledge.

We have provided a basic guide to alcohol content below to assist your completion.

- A 750ml bottle of wine contains 10 units.

- A standard (175ml) glass of wine contains 2 units.

- A single small shot of spirits (25ml) contains 1 unit.

- A standard 70cl bottle of spirits contains 28 units.

- A pint of 3.6% strength lager/beer/cider contains 2 units.

- A pint of 5.2% strength lager/beer/cider contains 3 units.

How many units of alcohol do you drink a week?

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

General Health

What is your current height?

What is your current weight?

Do you have any of the following diseases?

Asthma

Cancer

Diabetes

Chronic Heart Disease

Chronic Kidney Disease

Chronic Lung Disease

Epilepsy

Stroke / TIA

Hypertension (high blood pressure)

Hypothyroidism (underactive thyroid)

Mental Health (give details below)

Previous Operations (give details below)

Please give details of any Mental Health, Previous Operations or any other significant medical history: Please give details of any Allergies:

Are you on current medication (repeat)?

Yes

Your Recent repeat medication slip

Please add a photo of your most recent repeat medication slip if you have one.

Choose File No file chosen

Medical History?

Please give details of family (parents, siblings, grandparents) medical history, any major operations or whether they have any of the following conditions: Asthma, Cancer, Diabetes, Chronic Heart Disease, Chronic Kidney Disease, Chronic Lung Disease, Epilepsy, Stroke / TIA, Hypertension (high blood pressure), Hypothyroidism (under-active thyroid), Mental Health or Previous Operations:

Have you been registered here previously?

Have you been registered here previously?

Yes

Are you a full time carer for a dependant person?

Yes

If yes, please give name, address and telephone number:

Medication

Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.

Moved from Abroad

Have you moved to the UK from abroad?

Have you moved to the UK from abroad?

Yes

Have you had a blood transfusion before 1996?

Have you had a blood transfusion before 1996?

Yes

Have you had a Hepatitis C blood test?

Have you had a Hepatitis C blood test?

Yes

Correspondence

Please tick this box if you wish to receive correspondence from us in Welsh.

Carers

Do you have a carer?

Yes

If yes, please give name, address and telephone number:

Special Circumstances

Please tick any/all that apply

I am an Asylum Seeker

I am Housebound

I have communication difficulties

I am registered deaf

I am registered disabled

I am registered blind or partially sighted

I live in a nursing home

I live in a residential home

I live in a community psychiatric home

I live in a children's home

I have a carer

Submit your Request

Thank you! Your submission has been received!

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FAMILY DOCTOR SERVICES REGISTRATION - GMS1

Your Details

Please help us trace your previous medical records by providing the following information

If you are from abroad

Were you ever registered with an Armed Forces GP

If you need your doctor to dispense medicines and appliances*

NHS Individual Health Record Opt-Out

Correspondence

Your Signature

Language preference

Communication Consent

HEALTH QUESTIONNAIRE

What is your ethnic group?

White:

Mixed:

Asian or Asian British:

Black or Black British:

Other ethnic group:

Other options:

Smoking habits

Alcohol Consumption

General Health

Your Recent repeat medication slip

Medical History?

Medication

Moved from Abroad

Correspondence

Carers

Special Circumstances

Submit your Request

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