Patient Demographic Form
Name
We use this so we know who you are and to trace and verify your NHS number
Address
If postcode or address is incorrect or missing, important letters may be delayed or misdirected
Home telephone number
May be used to contact you directly and to re-arrange appointments.
Mobile phone number
May be used to remind you about scheduled appointments (e.g. text message reminders regarding for future appointments)
Email address
May be used to remind you about scheduled appointments (e.g. email reminders regarding for future appointments)
Date of birth
Used to calculate age-related indicators and verify your NHS number
Previous name
Allows us to identify potential duplicate records at registration
Marital status
We ask this to comply with the Equality Act. We use this to help service planning and monitoring trends in health inequalities.
GP
Ensures important information is sent back to your GP to keep them informed of your care e.g. clinic letters and discharge summaries.
Religion / Belief
We live in a society with a widening and diverse mix of religions and beliefs. We need to take this into account when developing our services. It will also help to inform us of any dietary requirements or specific requirements you may have.
Next of Kin
Emergency contact that you identify which is used if we cannot contact you or if you become unwell unexpectedly.
Sexual Orientation
We ask this to comply with the Equality Act. We use this to help service planning and monitoring trends in health inequalities.
Smoking Status
We use this to promote our Stop Smoking Service to provide advice and support to patients who wish to quit smoking
Occupation
Used to identify potential health issues linked to your current or previous occupation
Ethnicity
Used for service planning and studies of health inequalities. This is to ensure all patients receive excellent healthcare.
Disability, Maternity & Pregnancy, and Gender details
We ask these questions to comply with the Equality Act and use the data to help service planning, monitoring trends in health inequalities, and to provide the best patient experience possible by identifying any additional supported needed during visits