Queen's Park - NHS GP

Change of Contact Details

First Name(s)(Obbligatorio)

Surname:(Obbligatorio)

Date of Birth

Email:(Obbligatorio)

Old Postcode(Obbligatorio)

Old Home Tel(Obbligatorio)

New Address(Obbligatorio)

New Tel(Obbligatorio)

Other members of your family requiring a change of address (if registered here)

Comments and Suggestions Form

This is the easiest way to make a complaint or leave a comment for us.

What kind of comment would you like to send? Remember this form is not for medical matters.

What would you like to say? Enter your comments in the space below

Your contact details

Your telephone number:

Requesting Fit Note (Med3)

The more information you put in this form, the more opportunity we have to help you with your Fit note request

Date of birth:(Obbligatorio)

First name:(Obbligatorio)

Surname:(Obbligatorio)

Email:(Obbligatorio)

Postcode:(Obbligatorio)

Telephone:(Obbligatorio)

The next part of this form, is you opportunity to clarify why you are asking for a fit note.

Medical reason for sick note request:(Obbligatorio)

Proposed Fit Note Start Date(Obbligatorio)

Proposed Fit Note End Date(Obbligatorio)

Why do you feel that your medical condition stops you from working?(Obbligatorio)

What investigations/treatment have you been doing/taking for the above medical condition?(Obbligatorio)

What evidence do you have from your specialist specifying that you cannot work?(Obbligatorio)

Please email any supporting documents to docman.e84066@nhs.net

Alcohol Questionnaire for Adults

This is the easiest way to make a complaint or leave a comment for us.

Your contact details

First name:(Obbligatorio)

Last name:(Obbligatorio)

Date of birth:(Obbligatorio)

Home phone:(Obbligatorio)

Work phone:(Obbligatorio)

Mobile phone:(Obbligatorio)

Home address:(Obbligatorio)

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day?

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Application to Register with a General Medical Practitioner

Patient's Details

Please complete the text boxes and tick where appropriate

Surname:(Obbligatorio)

First Name(s):(Obbligatorio)

Birth country:(Obbligatorio)

Birth town:(Obbligatorio)

Home address:(Obbligatorio)

Postcode:(Obbligatorio)

Telephone:(Obbligatorio)

Date of birth:(Obbligatorio)

Your previous address:

Name and address of previous GP while at previous 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

If you are returning from the armed forces

Address before enlisting:

Service/Personnel No.

Enlistment date:

Date:

NHS Organ Donor Registration

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

For more information, please ask for the leaflet on joining the NHS Blood Donor Register Preferred address for donation: (if different from above, e.g. place of work)

Supplementary questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Name parent or guardian:

Relationship to patient:

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

If yes, please enter details from your EHIC or PRC below:

Date of birth:

Personal Identification Number:

Expiry date:

Identification number of the institution:

Identification number of the card:

From:

To:

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments.

Carer details

First name:(Obbligatorio)

Last name(s):(Obbligatorio)

Address:(Obbligatorio)

Date of birth:(Obbligatorio)

Telephone:(Obbligatorio)

Details of Person Being Cared For

Date of birth:

What relation is the person you care for?

Asthma Annual Review Questionnaire

Date of birth:(Obbligatorio)

Home phone:(Obbligatorio)

Mobile phone:(Obbligatorio)

Email:(Obbligatorio)

Home address:(Obbligatorio)

1. When was your asthma diagnosed?

2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of sleeping difficulties:

3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

4. How often do you use your blue inhaler?

Details of inhaler use:

If yes, do you know your best PEFR value

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

If 'Yes', please answer the following:

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?

Change of Contact Details

First Name(s)(Obbligatorio)

Surname:(Obbligatorio)

Date of Birth

Email:(Obbligatorio)

Old Postcode(Obbligatorio)

Old Home Tel(Obbligatorio)

New Address(Obbligatorio)

New Tel(Obbligatorio)

Other members of your family requiring a change of address (if registered here)

Comments and Suggestions Form

This is the easiest way to make a complaint or leave a comment for us.

What kind of comment would you like to send? Remember this form is not for medical matters.

What would you like to say? Enter your comments in the space below

Your contact details

Your telephone number:

New Patient Health Questionnaire for Adults

Your contact details

First name:(Obbligatorio)

Surname(s):(Obbligatorio)

Date of birth:(Obbligatorio)

Address:(Obbligatorio)

Telephone:(Obbligatorio)

Information about you

What is your height?(Obbligatorio)

What is your weight?(Obbligatorio)

What is your first language?(Obbligatorio)

If other, please specify

Name and Address of Previous GP

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place:

Have you ever suffered from? (tick as appropriate)

If yes, please state the year(s) when were you first diagnosed?

Please list any medicines being taken and the amount:

If yes, please give details:

If so, what and when?

Have you ever suffered from? (tick as appropriate)

If yes to any of these, please state the year(s) when were you first diagnosed?

Do you have any other mental health issues? (If yes please give details)

Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)

If yes please give details:

(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

If 'yes', please state when, where and the result:

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

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

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

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Please give name, address, telephone number and relationship of next of kin:

Have you had a flu vaccination? Enter date or 'never':

Have you had a pneumococcal vaccination? Enter date or 'never'

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Registering with a GP surgery outside the area you live?

You do not need to register with a GP surgery in the area you live.

You can register with a surgery that's more convenient, for example closer to your work or your children's school..

The GP surgery can refuse registration for reasons such as they are not taking new patients or it's too far away from your home and you need home visits.

Your details

First name:(Obbligatorio)

Last name(s):(Obbligatorio)

Address:(Obbligatorio)

Date of birth:(Obbligatorio)

Mobile(Obbligatorio)

Reason for registering with our practice in London

Do any of the following reasons for London GP Registration apply?(Obbligatorio)

Terms of Registering with GP far away from home.

The surgery will decide if they can accept you as a regular patient or accept you without home visits.

Because of the distance to your home, the GP surgery might not be able to offer home visits.

If you are not well enough to go to the GP surgery, other arrangements might be made.

Registering with a practice further away from home can affect decisions about referrals for hospital tests and treatment, or access to community health services

Additionally the offer of Cancer Screen Services and practice based Blood Tests and Investigations maybe a long distance for you to travel

Do you accept the Terms of Registering with a GP far away from home?

Do you accept the Terms of Registering with a GP far away from home?(Obbligatorio)

Repeat Prescription Request Form

Full name:(Obbligatorio)

Date of birth:(Obbligatorio)

Daytime tel:(Obbligatorio)

Patient ID:(Obbligatorio)

You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time. Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending

Please do not include medical problems here - these should be discussed with your doctor

Request to Register for Online Services

Your details

First name:(Obbligatorio)

Last name:(Obbligatorio)

Date of birth:(Obbligatorio)

Home tel::(Obbligatorio)

Signing Up For Patient Reference Group

If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.

Date of birth:(Obbligatorio)

First name:(Obbligatorio)

Surname:(Obbligatorio)

Email:(Obbligatorio)

Postcode:(Obbligatorio)

Telephone:(Obbligatorio)

The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.

The General Practice Assessment Questionnaire (GPAQ)

Firstly, please tell us the name of your usual doctor

1. In the past 12 months, how many times have you seen a doctor from your practice?

2. How do you rate the way you are treated by receptionists at your practice?

3 a) How do you rate the hours that your practice is open for appointments?

4 a) Thinking of times when you want to see a particular doctor, how quickly do you usually get to see that doctor?

4 b) How do you rate this?

Search

Queen’s Park
(Chamberlayne Road Surgery)

Ilford

Neasden

New Cross

Queen’s Park

Watford

Wembley Central

Wembley Park

Willesden

What kind of comment would you like to send? Remember this form is not for medical matters.

Patient's Details

Patient's Details

If you are from abroad

If you are returning from the armed forces

NHS Organ Donor Registration

NHS Blood Donor Registration

Supplementary questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

Contact details

What kind of comment would you like to send? Remember this form is not for medical matters.

Your contact details

Queen’s Park(Chamberlayne Road Surgery)

Change of Contact Details

Comments and Suggestions Form

What kind of comment would you like to send? Remember this form is not for medical matters.

Your contact details

Sick Note Request form

Alcohol Questionnaire for Adults

Application to Register with a General Medical Practitioner

Patient's Details

Patient's Details

If you are from abroad

If you are returning from the armed forces

NHS Organ Donor Registration

NHS Blood Donor Registration

Supplementary questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

Are You A Carer?

Asthma Annual Review Questionnaire

Contact details

Change of Contact Details

Comments and Suggestions Form

What kind of comment would you like to send? Remember this form is not for medical matters.

Your contact details

New Patient Health Questionnaire for Adults

Your contact details

Information about you

Previous GP

Medical Information

Carers

Wills

Women

Smoking

Alcohol

Family History

Next of Kin

Contacting you

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Registering with a GP surgery outside the area you live?

Repeat Prescription Request Form

Patient 1 details

Request to Register for Online Services

Signing Up For Patient Reference Group

The General Practice Assessment Questionnaire (GPAQ)

Travel Questionnaire

Your Accessibility Needs

Sick Note Request form

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Queen’s Park
(Chamberlayne Road Surgery)