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All questions marked with a * are mandatory

Patient's Details
I consent to sharing my records with the following:
Next Of Kin
Planning for the future
Is there an Enduring Power of Attorney for Health and Wellbeing?:
Including postcode
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Is there a Deprivation of Liberty Order in place?:

The surgery would like all our Nursing Home residents to have an individualised advanced care plan detailing their plans and wishes for their future care. 

  • We will finalise this with the patient, relatives and nursing home staff when we visit. 
  • It can be very helpful if relatives can attend when the doctor visits – if they would like to attend please let us know so we can schedule the visit to suit.
Have you made an Advance Care Plan with your care home team?:
This is an informal discussion about how you might want to be treated in the future if your health deteriorates. You can and should involve your family with this.

We will ask you some questions later in this form to help 'Plan for the Future', it will be quite obvious and you will be asked to confirm you still wish to create one.

Have you made a decision about whether you would like cardio-pulmonary resuscitation?:
It does not affect any other aspect of your care. The care home staff and your family may be able to help you come to a decision about this
Your decision: *
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Information So We Can Trace Your Medical Records
Have you been registered here before?:
Previous Details
If You Have Ever Served In The Armed Forces Please Complete This Section
If You Are From Abroad
If You Are Not Ordinarily Resident In The UK

You are defined as an Ordinary Resident if you are living in the UK on a lawful, voluntary and appropriately settled basis for the time being

Smoking Status
Please complete if you are 12 years or older: *
Alcohol Use

What does 1 unit of alcohol look like?

Each of the examples depicts 1 unit of alcohol based on the Alcohol by Volume (ABV) against the Volume (ml) displayed.

  • Cider

    Cider 218ml

    Standard 4.5% ABV

  • Wine

    Wine 76ml

    Standard 13% ABV

  • Whisky

    Whisky 25ml

    Standard 40% ABV

  • Beer

    Beer 250ml

    Standard 4% ABV

  • Alcopop

    Alcopop 250ml

    Standard 4% ABV

Alcohol Use Screening

Please tick the answer for each question

Men: How often do you have EIGHT or more drinks on one occasion?:
Women: How often do you have SIX or more drinks on one occasion?:
How often during the last year have you been unable to remember what has happened the night before because you had been drinking?:
How often during the last year have you failed to do what was normally expected of you because of drink?:
In the last year has a relative or friend or a doctor or other health worker be concerned about your drinking suggested you should cut down?:

If the total is THREE or more please ask reception for our more detailed questionnaire

About Your Past Medical History

Please list all your current medications

Ensure you include inhalers, dressings and appliances. 
(or if you have copy of your previous surgery’s repeat medicines list please attach here.

If you are taking regular medication, we will need to see a copy of your previous surgery’s repeat medicines list before you are due to run out

Do you give consent for us to use Electronic Repeat Dispensing? ERD allows your GP to prescribe your regular medicines for a few months at a time, meaning you don’t need to order from us each time and they will be ready at your pharmacy when you need them:

We require your consent in order to exchange information with your pharmacy

Are you happy for third parties to collect your prescriptions? :
Do you have any allergies? : *
Family History: Please tick any of the following that apply to first degree relatives (parents, children, brothers & sisters):
Physical Details

Blood Pressure (over 16s). Please use the lowest set of values 

Ethnicity and Language
Ethnic Origin (Knowing your ethnic origin is important for some of our tests and may affect which medicines work best for you): *

You will now be taken to create your Advance Care Plan

Advance Care Plan

Planning Your Future Care

What is this Plan for?

This Care Plan is your opportunity to think ahead and write down what is important for you about your future care. This will enable those who care for you to take full consideration of your wishes and preferences, both now and when you approach the end of your life. 

Preparing this Plan on behalf of someone else 

In some situations a person may lack capacity to make a Plan for themselves. This may be because of cognitive impairment such as dementia, or any other condition affecting their ability to understand, weigh up or communicate their wishes. This plan may be completed by their next of kin or by someone appointed under a Lasting Power of Attorney for health and welfare. The following points should be considered in this situation 

What can be included in the Plan? 

You can use this plan in whatever way you like. You may like to include information about where and how you would like to be cared for at the end of life, the kinds of treatment you would like to have, and any other issues that are important to you. As it is entirely your plan, you can include or leave out anything you wish. This is not a legal document, and you do not have to include any legal information in it, if you don’t wish to. 

  • Where at all possible, you should include the person in these discussions and make all efforts to understand their wishes. Discussion with family, carers and those close to the person can help. 
  • The Plan is for you to consider “What the person would have wanted for their future and end of life care”. This may not be the same as what decisions you would like for them or for yourself. 
  • It is especially useful if you can indicate why you know their wishes, by for example including written or verbal statements they had made. 
  • Please document clearly in the Plan the names of those completing the form, and that this was done on behalf of the person, because they did not have the capacity to complete it themselves. 

Do I have to make a Plan?

No. You do not need to do this unless you want to. You may wish to talk about your wishes with family and health professionals instead. 

Should I talk to others about my Plan? 

You may find it helpful to talk about your future care with your family and friends, as well as with your healthcare professionals such as your nurse or GP. Sometimes this can be difficult because it might be emotional, or people may not agree. Often just having this discussion is very useful and makes it easier to bring difficult issues out in the open. It may be helpful to talk about any particular needs your family, friends or carers may have. If others do help you with your Plan, please write their names at the end. 

Can I change my Plan? 

You may find that your wishes about your care change over time. This is entirely normal and simply reflects that different things become more or less important at different times. If at any time you wish to review or change this Plan, you are free to do so. 

How do I complete the Plan? 

The questions in the Plan give a few ideas about what some people wish to write about. You do not have to answer all the questions. You may also add in any other pages or information you would like. You may not feel able to answer all the questions now, and you can always choose to complete or change it whenever you like. 

Will my wishes and preferences be met? 

What you have written in your Care Plan will always be taken into account when planning your care. However, sometimes things can change unexpectedly. Your Plan can help healthcare professionals know your wishes, when planning your care. 

After reading the above do you still with to create an Advanced Care Plan as part of this application process: *
Advanced Care Plan Questions

You have opted to start creating your Advanced Care Plan as part of this process, please answer as many questions as possible.

e.g. at home, care home, hospital or hospice
e.g. Would you like to have someone with you?
Please give details of any people you would like to be contacted, or wishes you may have.

Here are the responses you have previously supplied which have reference to this section.

  • Please return to page 3, if you need to amend your choices


  • Have you made an Advance Decision to Refuse Treatment? (previously known as a Living Will or Advance Directive): 
  • Have you made a decision about whether you would like cardio-pulmonary resuscitation?:  (If Yes, What is your decision: )
  • Is there an Enduring Power of Attorney for Health and Wellbeing? 
Advanced Care Plan Declaration
Has the Advanced Care Plan been completed on behalf of someone else: *
e.g. if the person is lacking mental capacity

Privacy Consent


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