Title: New Registrations at Urmston Group Practice
Author: emis2000
Last saved by: HINCHY, Hayley (URMSTON GROUP PRACTICE)
Company: Trafford PCT

Age 10 & Under ONLY

Urmston Group Practice New Patient Questionnaire

Name: | | Date of Birth: |
Address: | | Telephone Number: |
Postcode: | | Date Form Completed: |
Have you been registered with this Practice before? | YES  /  NO

Please ensure you keep the Practice up to date with any changes to your personal details

Please list any drug allergies and reactions.

Please provide a list of regular repeat medication.

Please list your past medical history - serious illness, operations, hospital admissions

Does the patient have any Learning Difficulties?

Please provide the names of parents/carers with parental responsibility:

Is the child under the care of social services?      Yes/No  (please circle)

Which School does the child attend?

Has the patient been vaccinated against:
Tetanus | Yes / No | Date: | | | Polio | Yes / No | Date: |

(If you have a record of your immunisations, please can you provide us with a copy)

Family History

Diabetes: | YES | NO
Please detail family member(s) age and relation to you

Heart Disease e.g. high blood pressure, heart attack, angina: | YES | NO
Please detail family member(s) age and relation to you

Stroke: | YES | NO
Please detail family member(s) age and relation to you

Asthma: | YES | NO
Please detail family member(s) age and relation to you

Breast Cancer: | YES | NO
Please detail family member(s) age and relation to you

Ethnic Origin

What is your Ethnic Group? Choose one section from A to E then tick the appropriate box to indicate your ethnic group

A: White
🖵British
🖵Irish
🖵Any other White background (Please Write in)

B: Mixed
🖵 White and Black Caribbean
🖵White and Black African
🖵White and Asian
🖵 Any Other mixed background (Please write in)

C Asian or Asian British
🖵Indian
🖵Pakistani
🖵Bangladeshi
🖵Any other Asian background (Please write in)

D Black or Black British
🖵 Caribbean
🖵 African
🖵 Any other Black background (Please write in)

E Chinese or other Ethnic Group
🖵 Chinese
🖵 Any other (Please write in)

🖵 Not stated

Why we are collecting information about your ethnic group

Everyone belongs to an ethnic group, so at the moment all our new patients are asked to describe their ethnic group.

We are collecting this information to help us:

• Understand the needs of patients from different groups and so provide better and more         appropriate services for you

• Identify risk factors – some groups are more at risk of specific diseases and care needs so ethnic group data can help treat patients by alerting staff to high-risk groups

• Improve public health by making sure that our services are reaching all in our local communities and that we are delivering our services fairly to everyone who needs them

• Comply with the law - the Race Relations (Amendment) Act 2000 gives public authorities a duty to promote race equality and good race relations and ethnic monitoring is important in making sure that race discrimination is not taking place.

The 16 ethnic groups used are standard categories for recording ethnic group information. Using these codes will help us to compare information about the groups using our services with information from the census which tells us about our local population. The list of groups is designed to allow most people to identify themselves.
The list is not intended to leave out any groups of people, but to keep the recording of ethnic information simple.

It is important to us that you are able to describe your own ethnic group. If you need to complete any of the boxes labelled ‘any other group’ then please give some details so that we can better understand your needs.

You do not have to complete the question but providing this information is very important. It will help us with diagnosis and assessment of your needs, and it will also help us to plan and improve our service. Experience shows that when people are asked their ethnic group, the proportion of people who choose not to answer is small.  

The information you provide will be treated as part of your confidential GP records and will not be shared with any other person or organisation. The NHS and social services have strict standards regarding data protection and your information will be carefully safeguarded.

If you have any concerns or questions regarding this request or you want to make any comments or complaint about the collection of this information or the way in which you have been treated by staff requesting this information please contact the practice manager.