New Patient Registration For Permanent Care Home Resident 

 
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All questions marked with a * are mandatory

Please include any relevant documents such as a patient summary or discharge summary with this registration form. Failure to fully complete the form will result in a delay with the registration.

Patient Details
Is patient's gender identity the same as the gender they were assigned at birth?:
What’s the patient's sexual orientation?: *
Patient consents to sharing their records with the following (tick all that apply): *
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Physical Details

Blood Pressure (Please use the lowest set of values) 

Health and Lifestyle
Smoking Status: *
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 has 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 drink?: *
In the last year has a relative or friend or a doctor or other health worker be concerned about your drinking suggested you should cut down?: *

Please ask reception for our more detailed questionnaire. Find out how to contact reception here

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Ethnicity and Language
Does the patient need an Interpreter Service?: *
Ethnic Origin: *
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Planning For The Future
Is there an Enduring Power of Attorney for Health and Wellbeing? : *
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Does the patient have a DNACPR in place? : *
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Is there a Deprivation of Liberty Order in place?: *
Does the patient have a ReSPECT form in place? : *
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Does the patient have a living will? (This formal, legally binding document expresses what treatment the patient may want or refuse in the future): *
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Patient's Medical History
Medical conditions: (Please tick any that apply):
Mobility: (Please tick any that apply): *

Please list all patients current medications
(Please include inhalers, dressings and appliances or attach a copy of the previous surgery’s repeat medicines list here)

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Information so we can trace the Patient's Medical Records
Has the patient been registered here before?: *
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Declaration

I declare that this patient is entitled to NHS services because they have been or intend to be ordinarily resident in the UK for a period of 6 months or longer. I am registering with Worthing Medical Group and authorise them to obtain the patients past medical records from their previous UK GP.

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Privacy Consent

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