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11/14/2019

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Home Address

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Membership Emails

Below is a sample of the emails you can expect to receive when signed up to bbbc.

Re: New Patient Registration F...

Raw Data Registration Structure Registration Form Text

Registration

20182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Place of birth

First name

Last name

Phone

Home address

Date of birth

Gender

Would you like us to contact you via text message in relation to your health and care and to remind you of your appointments?

Yes

No Which Health Centre would you like to register with? Read more about our Health Centres here.

Bromley by Bow Health Centre

St Andrews Health Centre

XX Place Health Centre Do you have a carer who looks after you?

Yes

No Do you look after anyone who is ill, frail, disabled or has mental health or emotional support needs, or substance misuse problems?

Yes

Does anyone in your family have heart disease or stroke?

Heart disease

Stroke

Both

Up to date tests to find cervical cancer make it the easiest female cancer to catch early. If you are a woman between 25 - 64 years of age, have you had a smear test in the last 3 to 5 years?

Yes

N/A Have you had 2 doses of MMR?

Yes

I don't know If you are under 25 years of age have you had the meningitis vaccine?

Yes

I don't know We offer all new patients an optional 15 minute new patient health check. In this check, a nurse or health care assistant will take a few measurements including your blood pressure, height and weight. You can also talk about any other areas of your health and wellbeing, including the subjects covered in this form. Would you like us to book you in a new patient health check?

Yes

No We recommend a routine sexual health check for those who are sexually active as many people will not suffer from any symptoms of sexually transmitted diseases. This can be done in the form of a blood test or urine test if you are a man, or a cotton bud swab you take yourself if you are a woman. Would you like us to confidentially book one for you?

Yes

No Do you smoke?

Yes

Are you interested in quitting smoking

Yes

N/A You might find that other parts of your life are affecting your physical health. We are here to provide support and guidance in these areas. Please tick every box that sounds interesting, and we�ll put you in touch with one of our team. Money Bromley by Bow Centre can support you to manage your money on a low budget, get advice on employment law, access benefits and welfare support, reduce your utility costs and deal with debt. You can also visit the Financially Inclusive Tower Hamlets website which

I'm interested Housing The advice team at Bromley by Bow Centre can help you with housing advice. You can also get in touch with your housing provider.

I'm interested Work Bromley by Bow Centre employment team can support you to find volunteering or work opportunities in the local area.

I'm interested Alcohol Bromley by Bow Centre can support you to manage your money on a low budget, get advice on employment law, access benefits and welfare support, reduce your utility costs and deal with debt. You can also visit the Financially Inclusive Tower Hamlets website which has lots of information www.fith.org.uk

I'm interested Computer Skills If you need support to learn how to use a computer, get online and access social media and other services you can attend digital inclusion classes at Bromley by Bow Centre.

Yes! I would like to receive updates via email about news and events from the Bromley by Bow Centre (Community Hub and Health Centres). View our Newsletter Privacy Policy.

Data Name	Data Type	Options
20182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Place of birth	Text Box
First name	Text Box
Last name	Text Box
Email	Text Box
Phone	Text Box
Home address	Text Box
Date of birth	Text Box
Gender	Text Box
	tel
	dropdown	01
	dropdown	01
	dropdown	01
	option	Would you like us to contact you via text message in relation to your health and care and to remind you of your appointments?
	option	Yes
	option	No Which Health Centre would you like to register with? Read more about our Health Centres here.
	option	Bromley by Bow Health Centre
	option	St Andrews Health Centre
	option	XX Place Health Centre Do you have a carer who looks after you?
	option	Yes
	option	No Do you look after anyone who is ill, frail, disabled or has mental health or emotional support needs, or substance misuse problems?
	option	Yes
	option	Does anyone in your family have heart disease or stroke?
	option	Heart disease
	option	Stroke
	option	Both
	option	Up to date tests to find cervical cancer make it the easiest female cancer to catch early. If you are a woman between 25 - 64 years of age, have you had a smear test in the last 3 to 5 years?
	option	Yes
	option	No
	option	N/A Have you had 2 doses of MMR?
	option	Yes
	option	No
	option	I don't know If you are under 25 years of age have you had the meningitis vaccine?
	option	Yes
	option	No
	option	I don't know We offer all new patients an optional 15 minute new patient health check. In this check, a nurse or health care assistant will take a few measurements including your blood pressure, height and weight. You can also talk about any other areas of your health and wellbeing, including the subjects covered in this form. Would you like us to book you in a new patient health check?
	option	Yes
	option	No We recommend a routine sexual health check for those who are sexually active as many people will not suffer from any symptoms of sexually transmitted diseases. This can be done in the form of a blood test or urine test if you are a man, or a cotton bud swab you take yourself if you are a woman. Would you like us to confidentially book one for you?
	option	Yes
	option	No Do you smoke?
	option	Yes
	option	Are you interested in quitting smoking
	option	Yes
	option	No
	checklist	N/A You might find that other parts of your life are affecting your physical health. We are here to provide support and guidance in these areas. Please tick every box that sounds interesting, and we�ll put you in touch with one of our team. Money Bromley by Bow Centre can support you to manage your money on a low budget, get advice on employment law, access benefits and welfare support, reduce your utility costs and deal with debt. You can also visit the Financially Inclusive Tower Hamlets website which
	checklist	I'm interested Housing The advice team at Bromley by Bow Centre can help you with housing advice. You can also get in touch with your housing provider.
	checklist	I'm interested Work Bromley by Bow Centre employment team can support you to find volunteering or work opportunities in the local area.
	checklist	I'm interested Alcohol Bromley by Bow Centre can support you to manage your money on a low budget, get advice on employment law, access benefits and welfare support, reduce your utility costs and deal with debt. You can also visit the Financially Inclusive Tower Hamlets website which has lots of information www.fith.org.uk
	checklist	I'm interested Computer Skills If you need support to learn how to use a computer, get online and access social media and other services you can attend digital inclusion classes at Bromley by Bow Centre.
	checklist
	checklist	Yes! I would like to receive updates via email about news and events from the Bromley by Bow Centre (Community Hub and Health Centres). View our Newsletter Privacy Policy.