Cleveland Clinic

Patient Registration Form: ADULT

Individual patient registration forms must be completed for each adult and young person over the age of 16.
Please complete clearly all relevant sections of this registration form. PRIMARY 
1. Patient Information

Title: Miss / Mr / Mrs / Ms / Mstr / Mx / Gender Identity: Female Male Trans Other

Single Married Civil Partnership

Family Name: Marital Status:
Separated Divorced Other
A: White Black Asian Mixed Other
Given Name(s): Ethnicity: Select A and B
B: British European Other

Known As: First Language: If not English

Previous Family Name: Resident Since: Month/Year /

Transferring from another Jersey GP Practice
Date of Birth:
Reason For Registering Re-Registering with GP Practice
Seen with the Practice:
Jersey SSD No/Card: New Resident In Jersey
By:
Jersey SSD HIF Status: Identification Confirmed: ID Seen
HIO HMA Private Yes No
(For Practice to complete) (Passport / Driving Licence) Type: By:

2. Home Address and Contact Information (For ID purposes Utility Bill/Bank Statement or Tax/SSD Notification dated within 3 months is valid)

Home Telephone:

Work Telephone:
Current
Home Address (1):
Mobile Telephone:

Personal Email Address:

Address Confirmed: Doc. Seen
Post-Code: Yes No
Dated within 3 months of issue Type: By:
Access Information:
for impaired patient visits

3. Previous Home Address (If less than three years at the current home address)

Previous Previous
Home Address (2): Home Address (3):

Date From / To: / Date From / To: /

4. Emergency Contact/Next of Kin Information

Title: Miss / Mr / Mrs / Ms / Mx /

Home Address
Family Name: & Post-Code:

Same as Section 2
Given Name(s):

Date of Birth: Home Telephone:

Relationship to Patient: Work Telephone:

Your Next of Kin: Yes No Mobile Telephone:

Consent for us to
Yes No Your Official Carer: Yes No
Discuss Your Record:

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5. Children Under 16 that you are the Parent or Legal Guardian (Registrations Form to be completed for all those registering with the practice)

Child Full Name: Date of Birth:

Child Full Name: Date of Birth:

Child Full Name: Date of Birth:

Child Full Name: Date of Birth:

Child Full Name: Date of Birth:

6. Previous/Existing GP Information

GP Name: Telephone Number:

Address:

Reason for Transferring:

7. Private Medical Insurance and Current Employer Information (The Patient is responsible for making all claims with their insurer)

Insurance Provider:

8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and Communication

Your Personal Information (Data Protection and Patient Privacy):

The information collected on this application form will be used by Cleveland Clinic (hereafter the ‘Practice’) for the purposes of healthcare related
services and practice administration. Personal information we hold about you is processed for the purposes of ‘Employment and Social Fields’
(Article 8) ‘Medical Purposes’ (Article 15) and ‘Public Health’ (Article 16) of the Data Protection (Jersey) Law 2018. This may require your personal
data including, relevant details of your medical history, to be shared with other approved healthcare providers for the purpose of referrals and for
other lawful purposes related to the Practice procedures. Further information on how we hold and process your data can be found in our Data
Protection and Patient Privacy Policy.

General Practice Central Services (GPCS):

All Jersey GP Practices and other approved healthcare service providers, such as the out-of-hours doctors, use a central medical records system
known as EMIS. This allows access to a ‘shared medical record’ to ensure that the provider or clinician has immediate up-to-date and accurate
information about your health and any current treatment you may be having. You do however have the right to ‘opt out’ of sharing some or all of
your medical records. Please ask us for more information and where appropriate an Opt-in/Out Form for completion. All approved healthcare
service providers with authorised access to GPCS have signed strict confidentiality agreements which are bound by the Data Protection (Jersey) Law
2018.

Your Declaration to us:

 I confirm that all the information I have given in this registration form is accurate to the best of my knowledge.
 I understand that the Practice has the right to accept or decline my registration application at any time.
 I understand that by attending a consultation with a GP or other healthcare professional of the Practice, I accept the Practice terms
of service and fee schedule issued and displayed in the Practice premises and as amended from time to time.
 I hereby agree to pay any incurred service fees from the Practice at the time of attendance or treatment.
 I expressly consent that on registration or prior to accepting any credit arrangement from the Practice, where appropriate a credit
reference check may be taken with an authorised credit reference agency and/or my previous medical practice(s).
 I give my express permission for the Practice to request information including my medical records from my previously registered GP
and I agree to reimburse the Practice for any charges and disbursements incurred relating thereto for the Practice being provided
with such information.
 I understand it is my sole responsibility to advise the Practice in writing of any changes made in respect of my personal information.

Signed: Print Name: Dated:

For Practice Use Only On EMIS By: Pre-Registration Regular Private EMIS Number:
Medibooks: Synchronised: Billing Pattern: Alerts:
Past medical records requested* Date: Requested By: Received Date:
Other GP Informed of Registration: Date: Informed By: Check Requested:
 Send copy of Page 2 section 8 (signed) to existing GP as authorisation to release medical records to the Practice and amend EMIS patient type
 Individual Form 2 to be completed for each child under age of 16
 Separate registration forms to be used for those aged 16 and over, Visitors or Secondary users of the practice.

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Medical History/Assessment Form
Patient Name: Date of Birth:

9. Patient Summary Medical History

Have you ever had any of the following Please Tick If answered ‘yes’ please give details.
Epilepsy, fits, blackouts, fainting turns or unexplained
1 Yes No
loss of consciousness?
2 Vertigo, dizziness, giddiness, problems with balance? Yes No

3 Recurrent headache or migraine? Yes No

Diseases of the nervous system e.g. neuritis, stroke,
4 Yes No
multiple sclerosis?
5 Chest pain, angina, heart disease or breathlessness? Yes No
Any visual defect e.g. scotoma, blindness in one eye,
6 Yes No
reduced visual field, blurred vision, coloured blind?
7 Raised or low blood pressure? Yes No

8 Any blood disorder? Yes No

Asthma, bronchitis, emphysema, pneumonia or any
9 Yes No
other lung disease?
Jaundice or any form of hepatitis or other liver
10 Yes No
problem?
11 Any kidney or bladder conditions? Yes No

12 Arthritis, gout, chondromalcia patellae or rheumatism? Yes No

Any metabolic disorder including diabetes, thyroid and
13 Yes No
adrenal gland disease?
Psoriasis, eczema, allergic skin rash or other skin
14 Yes No
disorder?
15 Any infectious diseases? Yes No
Anxiety/depression, mental breakdown or stress related
16 Yes No
problems?
17 Sleep related issues? Yes No

18 Substance misuse (e.g. drugs, steroids)? Yes No

19 Any malignancies or cancers? Yes No

20 Any operations or surgical procedures? Yes No

21 Ear or hearing problems? Yes No

Have you ever consulted an orthopaedic surgeon,
22 Yes No
chiropractor, osteopath or physiotherapist?
Current treatment. Are you currently attending a
23 hospital/GP for treatment or waiting for an Yes No
appointment?

24 Any other medical condition we should be aware of? Yes No

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10. Other Medical History

Allergies: Do you have any known allergies or do you have any adverse reaction to drugs or medication Yes No

If Yes please provide details:

Do you currently take any medication?: Yes No

If Yes please provide details:

Smoking History. Do you or have you ever smoked? Yes No

If Yes how much do you smoke per day: How long have you smoked for? Number of years given up?

What is your average intake of alcohol per week in units?: Units

(Pint of Regular Beer/Lager/Cider = 1 Unit / Standard Glass of Wine = 2 Units / Bottle of Wine = 10 Units / Single Measure of Spirits = 1 Unit)

Date of last cervical cytology/smear test: Date: Result:

Female Patients: over 18 years of age;
Date of last mammogram if carried out: Date: Result:

Please give further information that you feel may be relevant to your medical history.

11. Family Medical History (If Known)

Family Cause of Death
Age / Deceased Heart Disease Hypertension Diabetes Cancer Mental Health
Member (if known)

Mother

Father

Sister

Sister

Brother

Brother

Child

Child

12. Social Activities

Less than 1-3 Above
Exercise taken on a normal weekly basis None
1 Hour Hours 3 Hours

Physical exercise such as swimming, jogging, sports, gym workout

Cycling including to work and leisure time

Walking including to work and leisure time

Gardening/DIY

Which sports or other exercises do you do?

How would you describe your walking pace? Slow Steady Brisk Fast

For Practice Use Only Received By: On EMIS By: EMIS Number:

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