Child New Patient Questionnaire

Name*

First NameLast Name

Previous Surnames/Maiden Name

Date of birth*

Date

NHS No (if known)

Gender*

MaleFemaleOther

Home Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Current School

Street Address

Street Address Line 2

CityCounty

Post Code

Full name of adult registering child*

First NameLast Name

Relationship to child*

Parent/Guardians Email Address*

example@example.com

Parent/Guardian Telephone Number*

Parent/Guardian's Full Address*

Street Address

Street Address Line 2

CityCounty

Postcode

How would you like us to contact you about your child?*

LetterEmailTextPhone

Who has legal parental responsibility?*

MotherFatherBothOther

Mothers name*

First NameLast Name

Mothers NHS Number (if know)

Is the mother registered at this surgery?*

YesNo

Does mother reside with child?*

YesNo

Fathers name*

First NameLast Name

Fathers NHS Number (if known)

Is the father registered at this surgery?*

YesNo

Does father reside with the child?*

YesNo

If you have clicked other

Name

First NameLast Name

Relationship to child

Registered with this surgery?

YesNo

Is the address the same as the child?

YesNo

Please provide full address

Street Address

Street Address Line 2

CityCounty

Postcode

Is your child looking after someone?*

YesNo

Relationship to child

Does your child have a carer?*

YesNo

Carers Full Name*

First NameLast Name

Carers Phone Number*

Carers Address*

Street Address

Street Address Line 2

CityCounty

Postcode

Does your child need help with mobility/hearing/speaking?*

YesNo

Is your child housebound?*

YesNo

Childs ethnicity*

Is English your child's first language?*

YesNo

What is your child's main spoken language?*

Do you need an Interpreter?*

YesNo

What is your child's religion?*

Is your child currently*

HomelessA RefugeeAsylum SeekerNone of the above

Childs previous address in UK

Street Address

Street Address Line 2

CityCounty

Postcode

Name of previous Doctor while at this address

Address of previous doctors

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are there any serious illness/conditions that affects your child's parent or siblings?

Does your child have any chronic medical conditions?

Please give details

Has your child had any operations?

Please give details

Please list any tablets, medicines or other treatments your child is currently on

Has your child had any allergies or adverse drug reactions?

YesNo

Has your child had any allergies or adverse drug reactions?

YesNo

Please list what he/she is allergic to, what happens and when he/she had their first reaction

Does your child have any mental disabilities?

YesNo

Please give details

Please provide us with information about any immunisations your child has received. This is essential if they have received any vaccinations overseas.

If you are not sure which vaccinations your child has had, it would be helpful to bring along any records (eg your child’s red health book) when you next come to the surgery.

If other please state

EPS – (Electronic Prescription Service) would you like to sign up for your child’s prescription to be sent electronically to your pharmacy?

YesNo

Name of nominated pharmacy

Medical record sharing allows your complete GP medical record to be made available to authorised healthcare professionals involved in your child’s care. You will always be asked your permission before anybody looks at the shared medical record.

Do you give permission to share your child's GP record?

YesNo

Summary Care Records contain details of your child’s key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughtout England. You will always be asked your permission before anybody looks at your child’s Summary Care Record. Ask your GP about the optional “Additional Information” choice.

Do you want your child to have a summary care record?

YesNo

I would like the child named above to be joined in the NHS Organ Donor Register as someone whose organs may used for transplantation after their death.

Please type full name as signature

Do you give permission for someone other than a parent/guardian to accompany your child to an appointment?

YesNo

Please type full name as signature consent

New Patient Registration Questionnaire(Child: Under 16 Years Old)

Patient Details

About you (Parent/Guardian)

Carers Information

Medial Records

Past Medical History

Vaccination History

Sharing your child's medical record

NHS Organ Donor Registration

Permission