Student Patient Registration for
Bradford Student Health Service

Please fill in your details and click Submit when complete. * = compulsory

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 Student Health Service to do so.
Please do not use this form to update your address or other details.

* Title:
Please enter all your first names in full
 
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
* Gender:
 
* Select your new University address from the list below if you are staying in University accommodation
Address in Bradford:
Select your university accommodation address in Bradford from this list. Disregard if you are in other accommodations
or; Type in your new University address below if you are not staying in University accommodation 
Your address in Bradford if you are not in university accommodation. NOT your old home address
Enter your own telephone number. Preferably your mobile number
Enter your e-mail address
Please help us trace your medical records by selecting if you are a UK or International
student (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:
Part 2: Fill in if you come from the UK





Part 2: Fill in if you come from abroad (international student)
Date you think you will leave UK

Date you left UK if you had registered with a GP before
* Signature:
Please draw your unique signature in the box
   
Health Questionnaire
Current and past MEDICAL / SURGICAL /
MENTAL HEALTH CONDITIONS
 
Please specify name of condition and
year of diagnosis (if known):
FAMILY HISTORY
Is there a family history of any of the following before the age of 60?
              
MEDICATION
SMOKING
* Do you smoke?
    
    
For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818.
In addition, the number for the local Smoking cessation helpline is 01524 845145
*
ALCOHOL
How often do you have a drink containing alcohol?
How many units of alcohol do you drink in a typical day when you are drinking?
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?
EXERCISE
How often do you do exercise which makes you breathless and increase your heart rate?
* More or less than 5 thirty minute sessions per week?  
 cm  kg
SCREENING QUESTIONS
* During the last month, have you often been bothered
by feeling down, depressed or hopeless?
  
* During the last month, have you often been bothered by
having little interest or no pleasure in doing things?
  
     
IMPORTANT INFORMATION
It is practice policy to share information that is recorded on your clinical record with other clinical
staff that you are under the care of to ensure the best care is provided to you. For further
information please ask for an information leaflet or visit www.nhscarerecords.nhs.uk/carerecords.
Organ Donation
If you are interested in becoming an organ donor, please click this link to go to the organ donor
registration page, alternatively you can fill out the form below.
I would like to join the NHS Organ Donor Register as someone whose organs may be
used for transplantation after my death.
Please tick as appropriate:
Please note: The information you are submitting will be passed to the medical centre over the Internet which is not 100% secure. If you are worried about this you can instead obtain a form from the surgery which can be filled in and delivered by hand.
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