Child Questionnaire New Patient Registration Questionnaire(Child: Under 16 Years Old) Patient Details Name* First NameLast Name Previous Surnames/Maiden Name Date of birth* -Day -MonthYearDate 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 About you (Parent/Guardian) 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 Carers Information 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* White EnglishWhite Northern IrishWhite ScottishWhite WelchWhite CypriotWhite GreekWhite Greek CypriotWhite TurkishWhite Turkish CypriotWhite ItalianWhite PolishWhite KosovanWhite and Black CaribbeanWhite and Black AfricanWhite and AsianBangladeshi/British BangladeshiBritish AsianIndian/British IndianBlack BritishBlack CaribbeanBlack AfricanBlack NigerianBlack SomaliChineseJewishIranianArabLatin AmericanNorth AfricaOtherI do not wish to disclose 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?* Church of EnglandCatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah's WitnessNo ReligionPrefer not to say Is your child currently* HomelessA RefugeeAsylum SeekerNone of the above Medial Records Please help us trace your previous medical records by providing as much of the following information as possible. 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 Past Medical History Are there any serious illness/conditions that affects your child's parent or siblings? Diabetes Type 1 or 2AsthmaThyroid DisorderStrokeCOPDHeart Attack under 60CancerHigh Blood PressureOther 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 Vaccination History 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. BCG - BirthHepatitis B – Birth, 1, 2 and 6 months1st DTaP IPV, HiB – 8 weeks1st pneumococcal (PCV) – 8 weeks1st Meningitis – 8 weeks1st Rotavirus – 8 weeks2nd DTaP IPV, HiB – 12 weeks2nd Rotavirus – 12 weeks2nd pneumococcal -16 weeks2nd Meningitis B – 16 weeksHib/Meningitis C – 12 monthsMMR – 12 months3rd pneumococcal – 13 – 15 monthsPre-school booster (DTaP/Polio, MMR 2) – 3 years 4 monthsMen ACWY – 14 yearsOther 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 Sharing your child's medical record 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 NHS Organ Donor Registration 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. KidneysHeartLiverCorneasLungsPancreasAny part of the child's body Please type full name as signature Permission 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 Submit Should be Empty: