Newbury Street Practice Questionnaire

Do you have any allergies? *

Yes No

If yes, please state the allergy and reaction.

Do you currently smoke or have you ever smoked? *

Currently smoke

Ex-smoker

Never smoked tobacco

Vaper with nicotine

Vaper without nicotine

If you currently smoke/vape, please state how many per day or how often you vape (enter 0 if non smoker) *

If you used to smoke, how long ago did you give up and how many cigarettes per day did you smoke? *

Summary Care Record and Oxfordshire Care Summary - YOUR CHOICE

Please note that these records are NOT CONNECTED with the Health and Social Care Information Centre (HSCIC) single database care.data project and will ONLY be used for the purpose of enabling informed care to be supplied directly to you as an individual.

Your patient record is held securely and confidentially on the electronic system at your GP practice. 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 via:

1. The Summary Care Record: used nationally accross England

2. The Oxfordshire Care Summary: used locally accross Oxfordshire

In both cases, the information will be used only by authorised health care 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.

A parent or guardian can request to opt out children under 16 but ultimately it is the GP's decision whether to create the records or not, because of their duty of care to the child. If you are the parent or guardian of a child under 16 and feel that they are able to understand, then you should make this information available to them.

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