New Patient Registration Form Nottingham Trent University Student Health Centre (Clifton campus) Online Registration New Patient Registration Form Please only complete this registration form once. If you have previously submitted this form at any time please do not do so again unless advised by the Medical Centre to do so. Please do not use this form to update your address or other details.Have you ever registered with this practice before? Yes Optional No Optional Arrival Date at UniversityDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Title Mr Mrs Miss Ms Name First Name(s) Surname Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS Number (if known) OptionalGender Male Female Other Town and Country of Birth Please Fill in your NEW NOTTINGHAM ADDRESSAddress House / Flat Number and Street City /Area County / Town Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberEmail Enter Email Confirm Email May we contact you using Email? Yes No May we contact you using SMS Text? Yes No Emergency ContactName First Last Phone NumberRelationship How do you know this person?Please select if you are from the UK or abroad From UK From abroad Signature OptionalHealth QuestionnaireHeightcmWeightkgWhich best describes your normal exercise pattern per week?Excercise ImpossibleAvoid ExcerciseLight ExcerciseModerate ExcerciseHeavy ExcerciseCompetetive AthletePrefer not to answerWhich best describes your normal eating pattern?High FatModerate FatLow FatVegetarianPrefer not to answerEthnic origin OptionalAsian or Asian BritishIndianPakistaniBangladeshiChineseAny other Asian backgroundBlack, Black British, Caribbean or AfricanCaribbeanAfricanAny other Black, Black British, or Caribbean backgroundMixed or multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundWhiteEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundOther ethnic groupArabAny other ethnic groupReligion 1st Language Need interpreter Yes No Are you a carer? Yes No Do you have a carer? Yes No Please tick if you have, or have had, any of the following ILLNESSES or tick None: Asthma COPD Heart problems High blood pressure Diabetes Stroke Thyroid problems Mental health problems NONE of the above Please list any other existing or past SIGNIFICANT MEDICAL CONDITIONS including major operations and dates:Please list any CURRENT MEDICATION, including inhalers and contraception. Please specify dose:Please list any significant FAMILY HISTORY of illness:Please list any DRUG ALLERGIES or ALLERGIC REACTIONS:Please list any CURRENT MEDICATION, including inhalers and contraception. Please specify dose:Do you Smoke? Yes No Used to smoke How often do you have a drink that contains ALCOHOL? Never (0) Monthly or less (1) 2-4 times / month (2) 2-3 times / week (3) 4+ times / week (4) How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 (0) 3-4 (1) 5-6 (2) 7-9 (3) 10+ (4) How often do you have 6 or more standard drinks on one occasion? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) Do you have a Disability or Special Communication Needs? Yes No Women over 25Have you ever had a smear test? Yes Optional No Optional If you are over 25 and have not yet had a smear please make an appointment with the Practice Nurse. Have you had HPV Vaccination? Yes Optional No Optional NHS Records I agree to opt in I do NOT agree to opt in There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish. NHS Summary Care Record (SCR) – this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.