The Scottish Government have developed a pilot, to help support GP practices to provide new patient checks. This resource can be used as an aide-memoir by GP practice staff and is intended to help practices identify individual healthcare needs, ideally within six months of registration, and support the delivery of care appropriate to the identified needs. Use of the resource is optional. The type and content of checks tend to vary a great deal in Scotland, and this resource aims to facilitate a relevant, proportionate and consistent response capturing any individual additional needs.
The web based resource will help cover the legislative requirements, some of which are listed below:
- Equality Act
- Adults with Incapacity, Mental Health, and Vulnerable Adult Acts Child Protection and the Children’s Act
- Sign Language Act – BSL (all requirements of groups)
Patient Registration Forms:
Questions/Options:
| Level 1 | Level 2 | Level 3 | Level 4 | Level 5 |
| To which religion, religious denomination or body do you actively belong? | Christianity – Church of Scotland | |||
| Christianity – Roman Catholic | ||||
| Christianity other | ||||
| Buddhism | ||||
| Hinduism | ||||
| Sikhism | ||||
| Judaism | ||||
| Islam | ||||
| Other Faith/Belief | ||||
| No Religion | ||||
| Prefer not to answer | ||||
| Sexuality | Bisexual | |||
| Heterosexual | ||||
| Gay Man | ||||
| Lesbian/Gay Women | ||||
| Transgender | ||||
| Gender Reassignment | ||||
| Ethnicity | White | Scottish | ||
| English | ||||
| Welsh | ||||
| Northern Irish | ||||
| Irish | ||||
| Gypsy/Traveller | ||||
| Polish | ||||
| Any other white ethnic group, please write in | ||||
| Mixed or multiple ethnic groups | any mixed or multiple ethnic groups | |||
| Asian, Asian Scottish or Asian British | Pakistani, Pakistani Scottish or Pakistani British | |||
| Indian, Indian Scottish or Indian British | ||||
| Bangladeshi, Bangladeshi, Scottish or Bangladeshi British | ||||
| Chinese, Chinese Scottish or Chinese British | ||||
| Other | ||||
| African, Caribbean or Black | African, African Scottish or African British | |||
| Caribbean, Caribbean Scottish or Caribbean British | ||||
| Black, Black Scottish or Black British | ||||
| other | ||||
| Other ethnic group | Arab | |||
| Other | ||||
| New patient leaflet/information about practice distributed | Yes | |||
| No | ||||
| How will you attend the appointment | Open description | |||
| Wheelchair used | Manual | Motorised | ||
| Wheelchair helper | Transport to support motorised wheelchair | |||
| Wheelchair helper | ||||
| Support at Appointment | Translator/interpreter | What is required | ||
| Independent advocate or welfare attorney | ||||
| Male/Female health care professional | ||||
| Learning Disabilities | ||||
| Hearing Loss | Hearing loop | |||
| Hearing dog | ||||
| Visual loss | Guide dog | |||
| Chaperone | ||||
| Physical disability | ||||
| Communication | Phone | Interpreter line | ||
| Text | ||||
| Via carer/family | ||||
| Letter | Language | |||
| Large font | ||||
| Easy read | ||||
| Language | ||||
| Large font | ||||
| Easy read | ||||
| Braille | ||||
| Face time interpreting (deaf BSL users) | ||||
| Carer | Name | |||
| Address | ||||
| Telephone | ||||
| Email address | ||||
| Does this person attend with the patient | ||||
| Are you a carer | Relationship to person | |||
| Additional information | ||||
| Does the carer have a carers support plan | Has it been offered | |||
| Power of Attorney status/Welfare Guardian | ||||
| Next of Kin | Name | |||
| Address | ||||
| Telephone | ||||
| Email Address | ||||
| Additional Notes | ||||
| Smoke | Do you smoke? | Yes | No | |
| Smoke less than 1 (per day) | Never ever smoked | |||
| 1-9 (per day) | Given up smoking in the last year | |||
| 10-19 (per day) | Not smoked for more than 1 year | |||
| 20-39 (per day) | ||||
| More than 40 (per day) | ||||
| Smoke a pipe | ||||
| Smoke cigars | ||||
| Electronic cigarette | ||||
| Other forms of smoking/chewing/inhaling | ||||
| Would you like help to stop smoking? | Yes | No | ||
| Alcohol unit = 1 small glass of wine or 1 single measure of spirit or 1 half pint (standard strength) beer |
I never drink alcohol | |||
| I do drink alcohol | Less than 1 unit (per day) | |||
| Between 1 and 2 units (per day) | ||||
| Between 3 and 6 units (per day) | ||||
| Between 7 and 9 units (per day) | ||||
| More than 9 units (per day) | ||||
| Have you ever injected drugs | Yes | Illegal drugs | When was the last time you injected? | |
| New psychoactive substances | When was the last time you injected? | |||
| Performance enhancing drugs | When was the last time you injected? | |||
| No | ||||
| Prefer not to say | ||||
| Currently injecting drugs | Yes | Illegal drugs | When was the last time you injected? | |
| New psychoactive substances | When was the last time you injected? | |||
| Performance enhancing drugs | When was the last time you injected? | |||
| No | ||||
| Exercise | In the past week, on how many days have you been physically active for a total of 30 minutes or more? | 0-4 – Go to next question | 5-7 – Positive reinforcement | |
| If four days or less, have you been physically active for at least two and a half hours (150 minutes) over the course of the past week? | No – Go to next question | Yes – Positive reinforcement | ||
| Are you interested in being more physically active? | No – Physical activity leaflet | Yes – Brief advice and or brief intervention |
||
| What do you think are the main risks to your health | Open ended | |||
| Allergies and Intolerances | Drug related allergies | |||
| Non-drug related allergies | ||||
| Diet | Vegetarian | |||
| Non vegetarian | ||||
| Vegan | ||||
| Gluten free | ||||
| Others | ||||
| Are you taken any regular medication | Name | Dosage and Frequency | ||
| Medical Conditions | Heart disease | Aortic valve stenosis | approx date of diagnosis | |
| MI | approx date of diagnosis | |||
| Stroke | approx date of diagnosis | |||
| High blood pressure | approx date of diagnosis | |||
| Asthma | approx date of diagnosis | |||
| Diabetes | approx date of diagnosis | |||
| Chronic Obstructive Pulmonary Disease | approx date of diagnosis | |||
| Epilepsy | approx date of diagnosis | |||
| Hypothyroidism (Thyroid Deficiency) | approx date of diagnosis | |||
| Cancer | approx date of diagnosis | |||
| Chronic kidney disease | approx date of diagnosis | |||
| Any others | ||||
| Memory Loss | Are you or anyone else in your family concerned that you have memory loss? | Yes | Who | Problems are |
| No | ||||
| Mental Health | Past symptoms | Past medications | ||
| Current present symptoms | Current medications | |||
| Treatment received | ||||
| Patient perspective of present mental well-being | ||||
| Current issues, worries, or concerns | ||||
| Learning Disabilities including Autistic Spectrum Disorder | Type | Severity | ||
| Learning Difficulties e.g. Dyslexia | ||||
| What medication are you taking that you can get over the counter/herbal | Dosage and Frequency | |||
| Family History | Heart disease | Aortic valve stenosis | who was affected | age |
| MI | ||||
| High blood pressure | Who was affected | Age | ||
| Diabetes | Who was affected | Age | ||
| High Cholesterol | Who was affected | Age | ||
| Strokes | Who was affected | |||
| Cancers | Who was affected | |||
| Any others (including relevant occupations e.g. engineering, exposure to metals and substances) | ||||
| Immunisation History | ||||
| D TaP/IPV (vaccine protects against diphtheria, tetanus, pertussis (whooping cough) and polio.) | ||||
| D TaP/IPV/Hib (vaccine protects your child against diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenza type b (Hib) | ||||
| Td/IPV (protects against diphtheria, tetanus, pertussis (whooping cough) and polio) | ||||
| Hib/MenC (vaccine protects your baby against two of the causes of meningitis and septicaemia) | ||||
| HPV (The human papillomavirus (HPV) vaccine for girls aged 11 to 13 years helps protect against cervical cancer) | ||||
| MMR (protect you against measles, mumps and rubella) | ||||
| Pneumococcal | ||||
| Meningitis | Men B | |||
| MenC | ||||
| MenACWY | ||||
| Whooping cough | ||||
| Rotavirus | ||||
| BCG (protects your baby against tuberculosis) | ||||
| Hepatitis B | ||||
| Flu | ||||
| Shingles | ||||
| Travel vaccines | ||||
| Other | ||||
| Social History | Dependent vulnerable adult in household/ Adult Protection | Relationship to person | ||
| Vulnerable children in household/Child Protection | ||||
| Housing issues | ||||
| Use of food bank | ||||
| Lives alone – no chronic illnesses/conditions | ||||
| Lives alone – has chronic condition/s | ||||
| Pets | ||||
| Hobbies | ||||
| Employment Status (can select more than one) | Employed | Part-time | What do/did you do for work? | |
| Full time | What do/did you do for work? | |||
| Self Employed | What do you do for work? | |||
| Unemployed | ||||
| Student | Where are you studying | |||
| Looking for work | ||||
| Retired not working | ||||
| Retired but still working | What do/did you do for work? | |||
| New entrant from/holiday or a history of prolonged (more than 3 months) travel in? | Afghanistan | |||
| Angola | ||||
| Bangladesh | ||||
| Bhutan | ||||
| Botswana | ||||
| Cambodia | ||||
| Cameroon | ||||
| Central African Republic | ||||
| Chad | ||||
| Congo | ||||
| Cote d’Ivorie | ||||
| DR Congo | ||||
| Djibouti | ||||
| Equatorial Guinea | ||||
| Ethiopia | ||||
| Eritrea | ||||
| Gabon | ||||
| Gambia | ||||
| Greenland | ||||
| Guinea | ||||
| Guinea-Bissau | ||||
| India | ||||
| Indonesia | ||||
| Iraq | ||||
| Haiti | ||||
| Kenya | ||||
| Korea | ||||
| Korea, DPR | ||||
| Kiribati | ||||
| Laos | ||||
| Lesotho | ||||
| Liberia | ||||
| Madagascar | ||||
| Malawi | ||||
| Marshall Islands | ||||
| Mauritania | ||||
| Micronesia | ||||
| Mongolia | ||||
| Mozambique | ||||
| Myanmar | ||||
| Namibia | ||||
| Nepal | ||||
| Nigeria | ||||
| Pakistan | ||||
| Palau | ||||
| Papua New guinea | ||||
| Philippines | ||||
| Moldova | ||||
| Sierra Leone | ||||
| Somalia | ||||
| South Africa | ||||
| Sri Lanka | ||||
| Sudan | ||||
| Swaziland | ||||
| Syria | ||||
| Tajikistan | ||||
| Tanzania | ||||
| Timor-Leste | ||||
| Tuvalu | ||||
| Uganda | ||||
| Vietnam | ||||
| Zambia | ||||
| Zimbabwe | ||||
| Specific to migrants/refugees | How long in the UK? | |||
| Circumstances of migration (forced or by choice) | ||||
| Housing/social issues | ||||
| Plans to return home? | ||||
| Women Only | Date of last smear | |||
| What was the result | ||||
| Where was it taken | ||||
| No. of pregnancies | ||||
| No. of children | ||||
| Are you pregnant now | ||||
| Are you currently using a method of contraception | ||||
| Breast screening | ||||
| Hormone Replacement Therapy | ||||
| Incontinence | Either | Both | ||
| Urinary | ||||
| Faecal | ||||
| Any miscarriages | ||||
| Men only | Poor urinary flow | |||
| Erectile dysfunction | ||||
| Abdominal aortic aneurysm | ||||
| Blood Pressure | Systolic BP | |||
| Diastolic BP | ||||
| Height | ||||
| Weight | ||||
| Abdominal Circumference | ||||
| Body Mass Index | ||||
| Pulse | ||||
| Urine | Sugar | |||
| Protein | ||||
| Blood | ||||
| Nitrites | ||||
| Leukocytes |