New Adult Patient Online Registration Form To register, complete the following steps: Contents Step 1 – GMS1 Form Non-urgent advice: Both steps are mandatoryYou must complete all steps to register. Step 1 – GMS1 Form Complete the following GMS1 form GMS1 Title Mr Mrs Miss Ms Mx Dr Other NHS Number: Optional Surname: First Names: Prev Surname: Optional Date of Birth Day Month Year Sex: Male Female Town and Country of Birth: Address Street Address Address Line 2 City Post code Telephone NumberMobile NumberEmail Address Enter Email Confirm Email Please help us trace your previous medical records by providing the following information:Are you from abroad? Yes No Are you in the Armed Forces? Yes No Previous Address Street Address Address Line 2 City Post Code Name of Doctor while at that address Address of previous doctor Street Address Optional Address Line 2 Optional City Optional Post code Optional If you are from abroad:Your first address where registered with a GP Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Optional If previously resident in UK, date of leaving Optional DD slash MM slash YYYY Date you first came to live in the UK Optional DD slash MM slash YYYY If you are from the Armed Forces:Address before enlisting Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Optional Service or Personnel number OptionalEnlistment date Optional DD slash MM slash YYYY Discharge date Optional DD slash MM slash YYYY If you need your doctor to dispense medicines and appliances:Not all doctors are authorised to dispense medicines. I live more than 1.6km in a straight line from the nearest chemist Optional I would have serious difficulty in getting them from the chemist Optional Emergency ContactName: Relationship: Optional Contact Number:Address Street Address Address Line 2 City Post Code I have filled in this form on behalf ofMyselfMy childRelativeFriendOtherNEW PATIENT QUESTIONNAIREPlease answer these questions to the best of your ability. The information will be used to update your personal medical record.Name Date Of Birth Day Month Year Phone Number Do you consent to receive text messages form us regarding your health, appointments etc.? Yes No Email Address What is your Occupation? Height cmWeight kgWhat is your smoking status?Please selectCurrent SmokerEx SmokerNever SmokedHow many cigarettes do you smoke a day? When did you stop smoking? DD slash MM slash YYYY Are you interested in advice on how to quit? Yes No Do you exercise? If yes, how much? Gentle Moderate Vigorous I do not exercise Do you follow a special diet? Vegetarian Vegan Diabetic No Diet Do you drink Alcohol?Please SelectYesNoHow often in the last year have you had 6 or more units (Female) or 8 or more units (Male) on a single occasion?Please SelectNeverLess than monthlyMonthlyWeeklyDaily / almost dailyHow often during the last year have you failed to do what was normally expected from you because of your drinking?Please SelectNeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?Please SelectNeverLess than monthlyMonthlyWeeklyDaily or almost dailyHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?Please SelectNoYes, but not in the last yearYes, during the last yearFAST scoreHow often do you have a drink containing Alcohol?Please SelectNeverMonthly2-4 times monthly2-3 time weekly4+ times weeklyHow many units do you drink on a typical day?Please Select0-23-45-67-810 or moreHow often during the last year have you found that you were not able to stop drinking once you had started?Please SelectNeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?Please SelectNeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you had a feeling of guilt or remorse after drinking?Please SelectNeverLess than monthlyMonthlyWeeklyDaily or almost dailyHave you or somebody else been injured as a result of your drinking?Please SelectNoYes, but not in the last yearYes, during the last yearTotal AUDIT scoreScoring: 0 to 7 indicates low risk 8 to 15 indicates increasing risk 16 to 19 indicates higher risk 20 or more indicates possible dependence Do you have a family history of:Heart disease over 60yrs Yes No Which Family Member Optional Heart disease under 60yrs Yes No Which Family Member Optional Stroke Yes No Which Family Member Optional Raised Blood Pressure Yes No Which Family Member Optional Diabetes Yes No Which Family Member Optional Cancer Yes No Which Family Member Optional Are you aged over 65? Yes No Have you had a fall in the last 6 months? Yes No How many falls? Do you have a contraceptive coil fitted? Yes No Which type of coil do you have? Mirena Copper I don’t know Major Illnesses OptionalPlease include datesPast Operations OptionalPlease include datesDo you have any allergies?Please selectYes – To a drug/MedicationYes -To something elseNoWhich Drugs/Medication? Optional What are your allergies? Are you on any regular medication?Please selectYesNoWhat medication? Have you recently come to the U.K. from a country which has a high incidence of tuberculosis e.g. Lithuania or Romania?Please selectYesNoIf you have had a cough or any unexplained weight loss recently please make an appointment to see one of the doctors.From which Country? Optional Are you a student?Please selectYesNoHave you had your MeningitusACWY vaccination?Please selectYesNoAre you Caring for Someone or does Someone Care for You?A Carer is a person who is looking after or is responsible for the care of a relative, friend or neighbour who is mentally or physically disabled or whose health is impaired by old age.Do you have a Carer? Yes No Name of Carer Carer's Contact Number Carer's AddressRelationship to you Please can we pass your carer details to Carers Bucks? Yes No Do you care for someone else who can’t manage without you? Yes No Please give details of the person you care for: Electronic PrescriptionsIf you have recently moved to the Amersham area and had nominated a pharmacy for your electronic prescriptions near your previous home, please confirm that you wish to cancel that nomination. If you do not cancel the nomination, all your prescriptions will continue to go to that pharmacy. Please cancel the pharmacy nomination from my previous address Yes No NEW PATIENTS WILL NEED A GP APPOINTMENT TO TRANSFER REPEAT MEDICATION. PLEASE ENSURE YOU HAVE SUFFICENT MEDICATION BEFORE REGISTERING WITH US AS IT CAN TAKE UP TO FOUR WEEKS TO BE REGISTERED.SUMMARY CARE RECORD – your emergency care summaryNHS England has introduced the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.GP practices are supporting Summary Care Records and as a patient you have a choice:Please selectYes I would like a Summary Care Record – you do not need to do anything and a Summary Care Record will be created for you.No I do not want a Summary Care Record – Please ask the receptionist for an opt-out form.For more information talk to the Patient Advice and Liaison Service (PALS), GP practice staff, visit the website www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.Do you consent to having an Enhanced Summary Care Record with Additional Information? Yes (recommended option) No The Department of Health has asked us to record the ethnic origin, and first language, of all new patients. Please tick the box which most accurately describes you: White – British White – Irish Other White background White/Black Caribbean White/Black African White/Asian Other mixed background Chinese Indian/British Indian Pakistan/British Pakistan Bangladesh/British Bangladesh Other Asian background Caribbean/British Caribbean African/British African Other Black background Other ethnic background Prefer not to say What is your first main spoken language? Will you need a translator when you see one of our medical team?Please selectYesNoUpload your ID Drop files here or Select files Max. file size: 50 MB. Upload proof of address Drop files here or Select files Max. file size: 50 MB. Must be dated within the last 3 months.THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE