Muswell Hill Practice New Patient Registration Form (GMS1) + Health Questionnaire

Before completing this form please check you are within our catchment area, or within the borough of Haringey if you are registering as an out-of-area patient.

Out-of-Area patients must also complete an out-of-area form, available on our website, and email it to our registration team: nclicb.tmhp.registrations@nhs.net

Please allow up to 10 working days for your registration to be processed. If you do not receive a confirmation text/email by this time please contact the practice and provide the date you completed your registration form so we can track it down.

This is a long form, it may be useful to have the following available if relavent to you: Your NHS Number, your previous doctors surgery address, the date you arrived in the UK, your Armed Forces personnel number and start date (if you served in the Armed Forces).

Initial Questions

Are you completing this form on behalf of... *

Myself

Someone else (State your relation to them)

Today's Date *

If someone else, state your relation to them:

Your Details

Please help us trace the patients previous medical records by providing the following

Ethnicity and languages

Please select your ethnic group *

What is your main language *

Other spoken languages

Do you need an interpreter?

Yes No

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

Your previous address in UK, if none please write n/a *

Name of previous GP while at previous address, if none please write n/a *

Address of that Doctor

Contact with the Surgery

Important questions to help you use our services

Do you want to receive text reminders to mobile telephones about appointments and other clinical services? *

Yes No

If yes, please provide a contact email address.

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 (DD/MM/YYYY) *

If you are returning from the armed forces

Address before enlisting

LEAVING DATE

Service/Personnel No.

Enlistment date

Next of Kin

Please give us the details of who to contact in case of emergency, this can be a friend or family member.

Title: *

Name *

Contact number *

Relationship to you *

Carer

A carer is someone who looks after an adult or a child with a chronic disease, mental health problem, learning or physical disability, sensory impairment or who are otherwise unable to care for themselves (i.e. this does not include a parent of a normal child)

Are you a carer? *

Yes No

If Yes, provide the details of the person you care for (Name and Relationship)

Do you have a carer? *

Yes No

IF Yes, provide their details, (Name of the carer, relationship and mobile contact details)

Communication Support

Height and Weight

Height (Please include Units)) *

Weight (Please include Units) *

Blood Pressure (if you cannot take your own blood pressure, please come into the surgery and speak to reception)

Smoking

Do you smoke? *

Yes No

Have you ever smoked? *

Yes

If Yes, How many cigarettes/tabacco do you smoke a day?

Would you like help with smoking cessation? *

Yes No

Alcohol

The questions below refer to a standard drink which means either: half a pint of ordinary beer/lager/cider; a single measure of spirits; a small glass of wine; or a small glass of sherry. Each answer is scored by a number of points, found in the brackets at the end of the answer. Please add up your points as you answer the questions, you will be asked for this number at the end of the section.

How often do you have a drink containing alcohol? *

IF you do drink alcohol, how many standard units do you have on a typical day? *

How often have you had 6 or more units if female, 8 or more if male, on a single occasion in the last year? *

Please add up your points from your answers to questions 1-3 (found in the brackets) *

How often during the last year have you found that you were not able to stop drinking once you had started? *

How often during the last year have you failed to do what was normally expected of you because of your drinking? *

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy session of drinking? *

How often during the last year have you had a feeling of guilt or remorse after drinking? *

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Have you or somebody else been injured as a result of your drinking? *

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Please add up your points from your answers to questions 5-11 (found in the brackets) *

Occupation

WHAT IS YOUR CURRENT OCCUPATION? *

Allergies

Please tell us about any allergies or any adverse reactions to medication prescribed in the past:

Are you allergic to anything? *

Yes No

Please list if any

Medication

If you are on 2 or more medications (not including the contraceptive pill), please list them below:

Electronic Prescriptions (EPS)

Prescriptions can now be sent direct to a pharmacy of your choice. This is called nomination. This can be set up with a pharmacy near to where you live, work or shop. You no longer have to visit the practice to pick up your paper prescriptions, they can be sent electronically to the pharmacy you choose saving you time. All you need to do is fill in the information below and the practice can set this up for you. Alternatively, you can ask your pharmacist to set this up. You can change or cancel your nominated pharmacy at any time. Please ask at reception if you would like any more information on EPS.

Please let us know the address of your pharmacy of choice *

Patient Agreement

Thank you for registering at The Muswell Hill Practice. We welcome you here and aim to provide a high standard of service to all our patients. In order for us to maximise the service we are able to give, we request that patients agree to the following requests. Patients will be warned should this happen and it may result in a removal from the practice list.

Summary Care Record Opt Out Form

A Summary Care Record is a way of telling health and care staff important information about a person. For people with a learning disability, autism or both a doctor might ask if they can add some additional information to the summary care record. This will mean if a person needs treatment by other services like emergency or urgent care they will have more information about them. If you choose to opt out, NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, or phone. If you have any questions, or if you want to discuss your choices, please contact the practice. It tells staff caring for someone about their medicines and allergies. This means they can look after the person if they are not at their usual doctor’s surgery.

Please let us know your Summary Care Record preferences: *

YES, I would like a summary care record

NO, I do not want to have a summary care record

If you are filling out this form on behalf of another person or a child, please fill your name and your relationship to the patient below:

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Page last reviewed: 30 April 2025
Page created: 10 July 2020

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Muswell Hill Practice New Patient Registration Form (GMS1) + Health Questionnaire

Muswell Hill Practice New Patient Registration Form (GMS1) + Health Questionnaire

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