Parkside Medical Centre Over 16s Questionnaire

Date of birth Required
Required
Mobile number Required
Required
Required
Required

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Carers

Do you have a carer?
Do you look after another adult/child with additional needs?

Please ask for a consent form should you wish any other person to have access to any information regarding yourself held by us.

Summary Care Record

Would you like a summary care record with core and additional information?

(Emergency care summary) If you answer no or do not answer, a SCR will NOT be created, an emergency the hospital will not be able to access your records

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Online Access

If you would you like a password for online services so you can book appointments and medication online, please ask reception and show some photo ID.

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Communication

We need to provide everyone with the opportunity to receive communications from us.

This could be to remind you of an appointment or to ask you to book a review of a medical condition/medication review or to tell you about flu clinics and other news. We want to be able to keep you up to date with information we believe helps you and keeps you informed.

Do you consent to us contacting you by text?
Do you consent to us contacting you by email?
Would you like to be a member of the Patient Participation Group? (VPPG)

As a member of the VPPG you would be the first group of patients to try out new ideas and services, and give your opinion on Practice matters. All contact with us would be via email.

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Smoking

Do you currently smoke?
Have you ever smoked?

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Electronic prescribing

Your prescriptions will be sent to a chemist electronically to a phamacy

Please state the name and postcode of the pharmacy you wish to use.

If you do not answer your prescriptions will be here for you to collect and take to a chemist of your choice.

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Alcohol

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male on a single occasion in the last 6 months?
Required