New patient combined registration form (Welsh) v1.001

Patient's details [Manylion y claf]

Title(Required)

Mrs

Miss

Other

Surname [Cyfenw](Required)

First name/s [Enw(au) cyntaf](Required)

Previous surname/s [Cyfenw(au) blaenorol]

Known name [Adnabyddir fel]

Mothers maiden name [Enw’ch mam cyn priodi]

Sex(Required)

Male [Gwryw]

Female [Benyw]

Date of birth [Dyddiad geni](Required)

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

NHS Number (if known) [Rhif GIG (os ydych chi’n ei wybod)]

Town and country of birth [Tref a gwlad eich geni](Required)

Current address [Cyfeiriad presennol](Required)

Postcode [Cod Post](Required)

Home telephone number [Rhif ffôn cartref](Required)

Mobile (if aged 13 and over) [Rhif ffôn symudol (os ydych yn 13 oed neu’n hŷn)]

Please help us trace your previous medical records by providing the following information [Helpwch ni i olrhain eich cofnodion meddygol blaenorol drwy ddarparu’r wybodaeth ganlynol]

Your previous address in UK, whilst registered with a GP surgery [Eich cyfeiriad blaenorol yn y DU, pan oeddech wedi’ch cofrestru gyda meddygfa meddyg teulu]

Name of previous GP practice while at that address [Enw’r practis meddyg teulu blaenorol tra yn y cyfeiriad hwnnw]

Address of previous doctor [Cyfeiriad eich meddyg blaenorol]

Postcode [Cod Post]

If you are from abroad [Os ydych o dramor]

Your first UK address where registered with a GP [Eich cyfeiriad cyntaf yn y DU lle roeddech wedi cofrestru gyda meddyg teulu]

Have you ever registered with a NHS GP in the UK? [Ydych chi erioed wedi cofrestru â Meddyg Teulu y GIG yn y DU?]

Yes [Ydw]

No [Nac Ydw]

If previously resident in UK, date of leaving [Os oeddech yn arfer byw yn y DU, dyddiad gadael]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Date you first came to live in the UK [Y dyddiad y daethoch gyntaf i fyw yn y DU]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Armed Forces [Lluoedd Arfog]

Have you ever served in the UK Armed Forces? [Ydych chi erioed wedi gwasanaethu fel aelod o luoedd arfog ei mawrhydi?](Required)

Yes [Ydw]

No [Nac Ydw]

If you are returning from the Armed Forces [Os ydych yn dod yn ôl o’r Lluoedd Arfog]

Address before enlisting [Cyfeiriad cyn ymrestru]

Service or Personnel number, BFPO Number [Rhif gwasanaeth neu bersonél, Rhif BFPO]

Enlistment date [Dyddiad ymrestru]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Discharge date [Dyddiad gadael]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

If you need your doctor to dispense medicines and appliances* [Os oes angen i’ch meddyg weinyddu meddyginiaeth a theclynnau meddygol*]

*Not all doctors are authorised to dispense medicines [*Nid oes awdurdod gan bob meddyg i weinyddu meddyginiaeth]

I live more than 1 mile in a straight line from the nearest chemist [Rwy’n byw mwy na milltir mewn llinell syth oddi wrth y fferyllydd agosaf]

Yes [Ydw]

I would have serious difficulty in getting them from a chemist [Byddai’n anodd dros ben i mi gael gafael arnynt gan fferyllydd]

Yes [Ydw]

NHS Individual Health Record [Eithrio o Gofnod lechyd Unigol y GIG]

I want to opt out of the Individual Health Record and prevent emergency care medical staff being able to access my key medical information. [Rwy’n dymuno eithrio o’r Cofnod lechyd Unigol ac atal staff meddygol sy’n darparu gofal brys rhag gweld fy ngwybodaeth feddygol allweddol.]

I have received enough information to make an informed decision and I acknowledge that opting out could be detrimental to my healthcare. Further information is available by visiting https://111.wales.nhs.uk/lifestylewellbeing/individualhealthrecord or by calling NHS 111 Wales by dialling 111. [Rwyf wedi derbyn digon o wybodaeth i wneud dewis gwybodus ac rwy’n cydnabod y gallai eithrio fel hyn amharu ar fy ngofal iechyd. Mae rhagor o wybodaeth ar gael yn https://111.wales.nhs.uk/lifestylewellbeing/individualhealthrecord?locale=cy&term=A neu drwy ffonio GIG 111 Cymru drwy ddeialu 111]

I wish to opt out [Rwy’n dymuno eithrio]

Further information [Gwybodaeth bellach]

Marital status [Statws priodasol](Required)

Ethnicity [Ethnigrwydd](Required)

Gender [Rhywedd](Required)

Language preference [Nodwch eich dewis iaith](Required)

Welsh [Cymraeg]

English [Saesneg]

Communication consent [Caniataid i gyfathrebu]

Please tick this box if you wish to receive correspondence in Welsh [Ticiwch y blwch yma os hoffech chi dderbyn gohebiaeth oddi wrthym yn y Gymraeg]

Yes [Ydw]

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccination reminders, to let you know that your prescription or your sick note is ready for collection and anything else relevant to your healthcare? [Ydych chi’n cydsynio i’r practis gysylltu â chi drwy neges destun er mwyn eich atgoffa am apwyntiad, eich gwahodd i archwiliad iechyd, eich atgoffa am frechiad, rhoi gwybod ichi fod eich presgripsiwn neu eich nodyn salwch yn barod i’w gasglu, ac unrhyw beth arall sy’n berthnasol i’ch gofal iechyd?](Required)

Yes [Ydw]

No [Nac ydw]

We have an electronic method of contact available for patients to contact the surgery for non urgent requests – do you consent for us to correspond with you via this method and supply us with a preferred e-mail address for this purpose? [Mae gennym ddull electronig o gysylltu y mae cleifion yn gallu ei ddefnyddio i gysylltu â’r feddygfa os oes ganddynt ymholiadau nad ydynt yn frys. Ydych chi’n cydsynio i ni gysylltu â chi drwy’r dull hwn, a rhoi cyfeiriad e-bost yr hoffech chi inni ei ddefnyddio at y diben hwn?](Required)

Yes [Ydw]

No [Nac ydw]

Email address [Cyfeiriad e-bost]

Enter Email [Nodwch eich e-bost] Confirm Email [Cadarnhewch eich e-bost]

Smoking [Ysmygu]

Do you smoke? [Ydych chi’n ysmygu?](Required)

Yes [Ydw]

No [Nac ydw]

How many cigarettes do you smoke per day? [Faint o sigaréts ydych chi'n eu smygu bob dydd?]

Do you use an electronic cigarette? [Ydych chi'n defnyddio sigarét electronig?]

Yes [Ydw]

No [Nac ydw]

Alcohol [Alcohol]

For the following questions please answer to the best of your knowledge. We have provided a basic guide to alcohol content below to assist your completion: [Atebwch y cwestiynau canlynol y gorau ag y gallwch chi, hyd eithaf eich gwybodaeth. Isod, mae canllaw syml ar faint o alcohol mae diodydd gwahanol yn ei gynnwys er mwyn eich helpu i roi ateb:]

A 750ml bottle of wine contains 10 units
[Mae potel o win 750ml yn cynnwys 10 uned]

A standard (175ml) glass of wine contains 2 units
[Mae gwydraid safonol (175ml) o win yn cynnwys 2 uned]

A single small shot of spirits (25ml) contains 1 unit
[Mae un joch bach o wirodydd (25ml) yn cynnwys 1 uned]

A standard 70cl bottle of spirits contains 28 units
[Mae potel safonol (70cl) o wirodydd yn cynnwys 28 uned]

A pint of 3.6% strength lager/beer/cider contains 2 units
[Mae peint o lager / cwrw / seidr â chryfder o 3.6% yn cynnwys 2 uned]

A pint of 5.2% strength lager/beer/cider contains 3 units
[Mae peint o lager / cwrw / seidr â chryfder o 5.2% yn cynnwys 3 uned]

Find out more about alcohol units on the NHS website [Unedau alcohol – GIG]

How many units of alcohol do you drink a week? [Sawl uned o alcohol ydych chi’n eu hyfed bob wythnos?]

Height and Weight [Taldra a phwysau]

Please tell us your most recent measurements for the following (if known) [Nodwch eich mesuriadau diweddaraf ar gyfer y canlynol (os ydych chi’n eu gwybod)] Please note, we may contact you to offer you support or advice if appropriate based on your submission. [Sylwer: Mae’n bosib y gwnawn ni gysylltu â chi i gynnig cymorth neu gyngor, os yw’n briodol, ar sail eich atebion.]

Height [Taldra]

Weight [Pwysau]

Further information

NB: The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. [Sylwer: Gall yr wybodaeth ganlynol rydych chi’n ei rhoi inni ein helpu i ddarparu gofal da ichi wrth inni aros am eich cofnodion meddygol blaenorol.]

Family History [Hanes teuluol]

Is there any of the following in your family (father, mother, brother, sister) before the age of 65? [Oes unrhyw un o’r rhain yn eich teulu? (tad, mam, brawd, chwaer) cyn iddynt fod yn 65oed?]

Heart disease [Clefyd y galon]

Stroke [Strôc]

Cancer [Canser]

Site of cancer? [Ble mae’r canser?]

Which family member? [Pa aelod o’r teulu?]

Medication [Meddyginiaeth]

Please give details of any medication which you take (prescribed or otherwise). [Nodwch fanylion unrhyw feddyginiaeth rydych chi’n ei chymryd (ar bresgripsiwn neu beidio)]

Please attach or forward us your most recent repeat medication slip if you have one. [Amgaewch eich slip meddyginiaeth reolaidd ddiweddaraf, neu anfonwch ef ymlaen atom, os oes gennych chi un.]

Allergies [Alergeddau]

Do you have any allergies? [Oes gennych chi unrhyw alergeddau?]

Yes [Oes]

No [Nac oes]

If Yes, to what?: [Os oes, i beth?]

Past Medical History [Hanes meddygol]

Please give details of any treatments/medical conditions: [Rhowch fanylion unrhyw driniaethau / cyflyrau meddygol:]

Carers [Gofalwyr]

Do you need/have anyone who looks after you or your daily needs as Carer? [Oes arnoch chi angen / oes gennych chi rywun sy’n gofalu amdanoch chi neu’n gofalu am eich anghenion dyddiol, fel gofalwr?]

Yes [Oes]

No [Nac oes]

If Yes, would you like them to deal with your health affairs here? [Os Oes, ydych chi eisiau iddyn nhw ddelio â’ch materion iechyd yma?]

Yes [Ydw]

No [Nac ydw]

(A member of reception staff can help with these arrangements) [(Gall aelod o staff y dderbynfa helpu i drefnu hyn)]

Do you care for anyone else? [Ydych chi’n gofalu am unrhyw un arall?]

Yes [Ydw]

No [Nac ydw]

(If Yes, please ask the reception staff about Carers support) [(Os ydych, gofynnwch i aelod o staff y dderbynfa ynglŷn â chymorth i ofalwyr]

Communication [Cyfathrebu]

Do you have any communication/information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you? [Oes gennych chi unrhyw anghenion o ran cyfathrebu / gwybodaeth yn ymwneud â cholli synhwyrau? Os oes, beth ydyn nhw a sut hoffech chi inni gyfathrebu â chi?]

Signature [Llofnod]

Your full name [Enw llawn](Required)

Today's date [Dyddiad](Required)

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Please select one option below(Required)

Signature of patient [Llofnod y claf]

Signature on behalf of patient [Llofnod ar ran y claf]

Privacy consent [Caniatâd preifatrwydd]

Not for urgent medical help [Nid ar gyfer cymorth meddygol brys](Required)

Yes, I understand this form is NOT for urgent medical help [Ie, rwy’n deall NAD yw’r ffurflen hon ar gyfer cymorth meddygol brys]

Consent [Caniatâd](Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
[Trwy gyflwyno’ch manylion, rydych yn cydsynio i ddarparu’r wybodaeth hon er mwyn gwella ein gwasanaethau i chi. Bydd y data a ddarperir gennych ar y ffurflen hon yn cael ei storio’n ddiogel ar ein gwefan, sydd wedi’i lletya gan drydydd parti. Ni fyddwn yn cadw’r wybodaeth hon ar y wefan am fwy na 7 diwrnod calendr. Ni fydd eich manylion cyswllt yn cael eu gwerthu nac eu rhannu â thrydydd parti. Rwy’n deall y gallaf ddirymu’r caniatâd hwn ar unrhyw adeg drwy gysylltu â’r practis. Gellir gweld ein polisi preifatrwydd ar y wefan hon.]

I agree to the privacy policy.