New patient questionnaire

One unit of alcohol is the same as half a pint of ordinary stregnth beer/larger, one small glass of wine, one single measurement of spirits, one small glass of sherry, one single measure of aperitifs.

Please select one option from each of the sections below and complete patient details. Failure to complete this section will result in a record of refusal to share being recorded.

Click here to view the differences between the Gloucestershire Shared Record and the Summary Care Records.

Your patient record will be held securely and confidentially on our electronic system. Your medical record contains notes taken during every consultation you have had with a doctor or nurse at your practice or community service. Your record is also likely to include copies of any letters you have written and notes relating to any phone calls made with the service that you have been in contact with and will also contain copies of letters from other hospitals and departments, including mental health assessments if you have ever had one.

 If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.  This information can now be shared electronically (with your permission) via:-  

 SCR – NHS Summary Care Record (used nationally across England)

• Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. At a minimum, the SCR holds important information about: current medication
• allergies and details of any previous bad reactions to medicines
• the name, address, date of birth and NHS number of the patient

The patient can also choose to include additional information in the SCR, such as details of long-term conditions, significant medical history, or specific communications needs.

Gloucestershire Shared Health and Social Care Information (Joining up your information – JUYI)  (Used locally across Glos).

JUYI is the secure online system for sharing information in Gloucestershire, giving local health and social care professionals directly involved in your care instant access to your health and social care records.

Sharing your electronic records with the people who look after you gives them the most up-to-date information about you and makes your care safer and more efficient and cost effective.

Enhanced Data Sharing Model L in SystmOne (EDSM)(Used nationally across all healthcare providers using SystmOne).

What is SystmOne? SystmOne is a computer system that GPs and other people looking after patients can use to record medical information and other relevant information discussed at your time of contact.

The combination of giving consent to both “Share Out” and “Share In” is a bit like having a door with a bolt on both sides- you need to have the door unlocked on both the inside and out in order to be able to open it. So for example: Imagine a patient receives care from 3 different services; a GP, a district nurse and a smoking clinic. They want the GP and the nurse to share information with each other and know their progress at the smoking clinic. But they DON’T want the smoking clinic to see any of their other medical information. In this example the patient would have consented to Share Out at all 3 services, but only providing consent for Sharing In at the GP and the District Nursing services and not the smoking clinic.

Your information will be used only by authorised healthcare professionals directly involved in your care. Your permission will be asked before the information is accessed, unless the clinician is unable to ask you and there is a clinical reason for access.

Parents, guardians or someone with power of attorney can ask for people in their care to be opted out, but ultimately it is the GP’s decision whether to share information, or not, because of their duty of care.

If the person signing below is not the patient, please also enter the signatory’s name and relationship to the patient, e.g. Parent, Guardian, Attorney