Weston Lane & Harefield Surgeries - CONFIDENTIAL NEW PATIENT QUESTIONNAIRE – CHILD (under 16) Welcome to Weston Lane & Harefield Surgeries. Please complete the following forms. We pride ourselves on offering a high standard of care, and this information is extremely valuable in achieving this. A receptionist will be happy to assist you with any queries you may have. Bring the form with you along with suitable identification. Acceptable identification documents are shown in the list below. IDENTIFICATION Birth certificate Letter from school Other form of ID Red book Passport If ‘Other’, please state type of ID shown: ABOUT YOU Surname: Forename(s): Previous surnames: Sex: Male Female Date of birth Town and country of birth: Address: Post code: Telephone: Mobile: If want to book REPEAT prescriptions or Appointments online, please provide your email address. Email: IF YOU ARE FROM ABROAD What was your first UK address where you registered with a GP? Address: Post code: Date you first came to UK? FAMILY MEMBERS Are other family members also registered/registering with Weston Lane & Harefield Surgeries? a) b) c) Weston Lane & Harefield Surgeries Reviewed: May 2015 Page 1 of 4 New patient questionnaire pack - CHILD Weston Lane & Harefield Surgeries - CONFIDENTIAL REGISTERED BEFORE? Have you been registered with the surgery before? Yes No CHILD’s NEXT OF KIN Name: Relationship to child: Telephone: Please tick the box which best describes your ethnic origin WHITE White British White Irish MIXED White and Black Caribbean White and Black African White and Asian ASIAN or ASIAN BRITISH Indian Pakistani Bangladeshi BLACK or BLACK BRITISH Caribbean African CHINESE Chinese DECLINE TO ANSWER Any other background? First language? Translator needed? Yes No IF REGISTERING A CHILD UNDER 5 I wish the child above to be registered with Weston Lane & Harefield Surgeries for Child Health Surveillance PERSONAL MEDICAL HISTORY If child is under 5 years Type of birth: (e.g. normal, forceps, Caesarean) Birth weight: Feeding: (Breast or bottle fed) MEDICAL ILLNESS Has your child ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below: Condition Weston Lane & Harefield Surgeries Reviewed: May 2015 Year diagnosed Page 2 of 4 Ongoing Yes No Yes No Yes No New patient questionnaire pack - CHILD Weston Lane & Harefield Surgeries - CONFIDENTIAL FAMILY HISTORY Have any close relatives (father, mother, sister, brother only) ever suffered from: (please indicate who in the boxes) Heart attack Stroke Diabetes High blood pressure Asthma Glaucoma Cancer IMMUNISATIONS Please provide details of your child’s immunisations with dates if possible. If your Red Book, please give it to Reception to photocopy. Immunisation Tetanus Whooping Cough Polio HiB Measles MMR BCG (TB) Meningitis Date: Immunisation Booster Booster: Tetanus Booster: Diphtheria Booster: Polio Booster: MMR Date: MEDICATIONS BRING YOUR REPEAT MEDS LIST OR MEDICATION BOXES WITH YOU Medication Dosage 1. 2. 3. 4. 5. * Before these can be prescribed, you will need to provide your current repeat card ALLERGIES Please list any drugs or substances (e.g. nuts, eggs) that you are allergic to (i.e. develops rash/swelling/anaphylactic shock – not side effects such as diarrhoea or nausea). Weston Lane & Harefield Surgeries Reviewed: May 2015 Page 3 of 4 New patient questionnaire pack - CHILD Weston Lane & Harefield Surgeries - CONFIDENTIAL CONSENT To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (e.g. Emergency Departments). Please read the accompanying leaflet which details what part of your record is extracted and how it is used to help other NHS organisations. If you wish to OPT OUT please complete the form found with this leaflet. HOW DO YOU PREFER TO BE CONTACTED? Can you confirm how you are happy for us to contact you and tell us which is your PREFFERED way to be contacted. Email Text Letter Telephone Yes Yes Yes Yes No No No No I prefer to be contacted this way I prefer to be contacted this way I prefer to be contacted this way I prefer to be contacted this way RESULTS BY TEXT: I would like to receive any test results by text: Yes I confirm that the information that has been provided is true to the best of my knowledge. Signature: Signature on behalf of patient Date: Signature of patient OFFICE USE: Checked by: Read coded by: Date: Date: Weston Lane & Harefield Surgeries Reviewed: May 2015 Page 4 of 4 New patient questionnaire pack - CHILD