Castle Quay Medical Practice Patient Registration Form: Adult (Primary) Individual patient registration forms must be completed for each adult and child over the age of 16. Please complete clearly all relevant sections of this registration form. Please complete all 7 pages 1. Patient Information Title: Miss / Mr / Mrs / Ms / Gender Identity: Female Male Trans Other Family Name: Marital Status: Single Married Civil Partnership Separated Divorced Other Name(s): Ethnicity: Select A and B A: White Black Asian Mixed Other B: British European Other Known As: First Language: If not English Previous Family Name: Resident Since: Month/Year / Date of Reason For Registering with the Practice: Transferring from another GP Practice Re-Registering with GP Practice New Resident In SSD Health Insurance Number: Seen By: Jersey SSD HIF Status: (For Practice to complete) HIO HMA Private Proof of ID Confirmed: (e.g. Passport / Driving Licence) Yes No Seen By: 2. Home Address and Contact Information (Please provide a copy of a utility bill/bank statement dated within 3 months) Current Home Address (1): Home Telephone: Work Telephone: Mobile Telephone: Personal Address: Post-Code: Proof of Home Address: Dated within 3 months of issue Yes No Seen By: Access Information: for impaired patient visits 3. Previous Home Address (If less than years at the current home address) Previous Home Address (2): Previous Home Address (3): Date From / To: / Date From / To: / 4. Emergency Contact/Next of Kin Information Title: Miss / Mr / Mrs / Ms / Home Address & Post-Code: Same as Section 2 Family Name: Name(s): Date of Birth: Home Telephone: Relationship to Patient: Work Telephone: Next of Kin: Yes No Mobile Telephone: Can Discuss Record: Yes No Main Carer of Patient: Yes No
This is one unit of alcohol… …and each of these is more than one unit AUDIT – C Questions Scoring system Your 0 1 2 3 4 How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times per month 2 - 3 per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1 -2 3 - 4 5 - 6 7 - 9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly or almost daily Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. from AUDIT- C (other side)
Remaining AUDIT questions Questions Scoring system Your 0 1 2 3 4 How often during the last year have you found that you were not able to stop drinking once you had started? Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly or almost daily How during the last year have you been unable to remember what happened the night before because you had been drinking? Less than monthly Monthly Weekly Daily or almost daily Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence TOTAL Score equals AUDIT C Score (above) + Score of remaining questions