WELCOME TO CAMBRIDGE MEDICAL GROUP
Today’s Date:
Child Registration Form (Under 16)
Please complete this confidential questionnaire (one for each member of the family
under the age of 16 to be registered with the Practice).
Please complete in BLOCK CAPITALS and tick the boxes as appropriate.
Please note when registering we will need to see and take a copy of your CHILDS
birth certificate and YOUR photo ID (i.e. passport/Driving Licence)
Please speak to a member of staff if you are having difficulty obtaining these.
Please complete a separate form for each child to be registered.
About Your Child
Surname
Forename
Home Number:
Address and Postcode
Mobile Number:
Date of Birth:
Town & Country of Birth:
Male:
Female:
Gender:
Housing
(Select one)
House
Maisonette
Flat
Mobile Home
Childs Previous Address
NHS Number (If Known)
Previous Post Code
Previous Doctor Telephone No.
Childs Previous Doctor Name & Address:
Previous data
released?
Yes
No
If applicable, date you
first came to live in Britain:
Childs
Height:
Feet / inches
(Please use the
machine in the
nursing suite if
you are unsure of
height or weight)
Kim King, Updated Oct 2015
cm
Stones / lbs.
kg
Childs
Weight:
1
C of E
Catholic
Other Christian (state)
Buddhist
Sikh
Jewish
Jehovah’s Witness
No religion
Childs
Religion:
Childs Ethnic Origin:
Hindu
Muslim
Other religion (state)
White (UK)
9i0
White (Irish)
9i1%
White (Other)
9i2%
Caribbean
9i3
African
9i4
Asian 9i5
Other Mixed
Background 9i6%
Indian /
Brit Indian 9i7
Pakistani /
Brit Pakistani 9i8
Bangladeshi / Brit
Bangladeshi 9i9
Other Asian
Background 9iA%
Other Black
Background
Chinese
9iE
Other
9iF%
Ethnic Category
not stated 9iG
(select one)
Childs main or 1st language
Spoken / Understood:
(select one)
Polish
Ukrainian
Does your child
require an
interpreter?
English
Hindi
Gujurati
French
German
Spanish
Yes
Urdu
Bengali
/Sytheti
Punjabi
Other:
(Please
Specify)
No
Medical Background:
Birth Weight or any
problems at birth?
Any developmental
Problems?
What illnesses has your
child had & When?
What operations has
your child had and
When?
What medical problems
does your child have at
present?
Please list any tablets,
medicines or other
treatments your child is
currently taking:
(incl. dose + frequency)
You can attach a repeat slip
from your previous practice if
you wish
Kim King, Updated Oct 2015
2
NO
YES – Please list
Is your child allergic to
any medications?
Diabetes
Are there any
serious diseases that
affect the child’s Parents,
Brothers or Sisters
(tick all that apply)
Heart
Attack
Breast Cancer
Heart attack under age of
60
High Blood Pressure
Thyroid Disorder
Bowel Cancer
Asthma
Stroke
Any other important Family Illness?
Your Child’s Immunisations
If your child is aged 0-5 years it is especially important that you provide us with as much information
you can about any immunisations your child has received. If you are not sure which vaccinations your
child has had please bring along any records (e.g. the child health book) when you next come to the
surgery.
Age Due
Birth
Onward
Vaccine
Tick if
Given
Date
Given
At GP
Surgery
At other
place (please
specify)
BCG
Hepatitis B (course of 4 injections at
birth 1,2 and 6 months0
2 months
1st DTP & Hib & Polio
1st Pneumococcal
1st Meningitis B Vaccination
3 Months
2nd DTP & Hib & Polio
1st Meningitis C
4 Months
3rd DTP & Hib & Polio
2nd Meningitis C & 2nd Pneumococcal
2nd Meningitis B Vaccination
Kim King, Updated Oct 2015
3
12 Months
1st MMR, Hib & Men C Booster
3rd Pneumococcal
15 months
2nd MMR (or 3 months after 1st MMR)
3years 4
months
Dip/Tet/Pertussis + Polio Booster
(pre-school booster)
Females Only:
Aged 1213years
1st HPV (human Papilloma Virus)
2nd HPV (Human Papilloma Virus)
Any other Vaccinations:
Please give details of
any other vaccinations
i.e. for travel
About You (Parent/ Carer or Legal Guardian)
Name of Parent/Guardian
Registering Child:
Mothers Name
Yes
No
Mother Registered with the
practice?
Yes
No
Yes
No
Father registered with the
practice?
Yes
No
Mother
Father
Mother at same address?
Fathers Name
Father at same address?
Both
Other
If other, please give details:
Who is the PRIMARY carer?
Name & Address of Current
School or Child minder
(if applicable)
Kim King, Updated Oct 2015
4
Yes
No
If yes, please supply name & contact details:
Does your family have a
Social Worker?
Name
Relationship
Please list the names of other
household members living
within the household.
(for example siblings,
relatives or friends)
1st language Spoken /
Understood:
(select one)
Polish
Ukrainian
English
Hindi
Gujurati
Urdu
French
German
Spanish
Other:
(Please
Specify)
Do you require
an interpreter?
Language?
Can You read
English
Bengali
/Sytheti
Yes
No
Yes
No
Punjabi
(even if it is not
your preferred
language?)
About You & Your Child
Specific Needs:
Please detail below any specific needs you have so the Practice can ensure they are identified and
accommodated by taking the appropriate action:
Please state any Sensory
You
Your Child
Impairment you have
(i.e. Speech, Hearing, Sight):
You
Your Child
Are you an ‘Assistance Dog’ User?
Please state any Physical disabilities
you have:
You
Your Child
Please state any Mental Health
Problems you have:
You
Your Child
You
Your Child
Please state any requirements you
have to be able to access the
Practice premises
You
Your Child
Please state any Religious or
Cultural needs:
You
Your Child
Please state any drug or alcohol
problems you have:
Kim King, Updated Oct 2015
5
Please state any specific nutritional
requirements you have:
Please state any phobias you have:
You
Your Child
You
Your Child
Summary Care Records.
The NHS are changing the way your health information is stored and managed.
The NHS Summary Care record is an electronic record of important information about your health including
Medications and allergies. It will be available to health care staff providing your NHS Care.
An information leaflet has been provided in your new patient registration pack.
Are you happy for your child
to have a Summary Care
Record?
Yes
No
More Time Required to decide:
Are there any additional comments you would like to add?
Patient Participation Group (Patients aged 14-16)
The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for making services
better.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with
developments within the Practice.
If you are interested in getting involved, please tick the box below and we will be in touch
Yes, I am interested in becoming involved in the Practice Patient Participation Group
(Please tick the “Yes” Box)
Yes
Please sign below to complete your child’s registration
Parent/Guardian Signature
Date
Thank You for taking the time to complete this
questionnaire.
Kim King, Updated Oct 2015
6
Staff Use Only:
Yes
No
Birth Cert & ID Verified
Summarise Urgently
Adult Registering child has Parental Responsibility?
Safeguarding Lead
Child Under 5 – Details passed to HV Team?
Staff Name
Kim King, Updated Oct 2015
Date
Completed
7