NEW PATIENT CHILD HEALTH CHECK (AGE 0-15) ( purple) April 11
DATE______________________________
EMIS No________________
Welcome to the practice! It can take a long time for your past medical record to be sent on to us. You can help us greatly by
answering these questions completely as possible, please ask your parent or guardian to help you.
NHS Number___________________
OR
Proof of entitlement to NHS i.e. E128/EU ID Card –State Document _________________Seen by____
SURNAME______________________________________
SCHOOL/COLLEGE________________________________
FORENAME____________________________________
EMPLOYMENT________________________________________
FORENAME____________________________________
WHO IS AT HOME WITH YOU___________________________
CALLING NAME_________________________________
ETHNIC ORIGIN_____________________________________
FIRST LANGUAGE____________________________
TELEPHONE NO______________________________________
DATE OF BIRTH_________________________________
PLACE OF BIRTH _____________________________
ADDRESS__________________________________________________________________POST CODE________________
Please list any operations or major illness that you have had or are under treatment for:
Details
Year
______________________________________
_____________________________________
______________________________________
Details
Year
________________________________________________
________________________________________________
________________________________________________
Are you on medication of any sort at the moment, if so, what?
Drug
Dose
Directions
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Do you have any allergy to medicines or anything else, if so what?___________________________
________________________________________________________________________________________
Do you or a member of your family aged under 60 have a history of:
(If so which family member ? ie mother, brother, uncle, grand parent etc.)
Diabetes_____________________________
Glaucoma___________________________
Blood Pressure_______________________
Stroke______________________________
Heart Problems______________________
Raised Cholesterol____________________
Tuberculosis_________________________
Epilepsy_____________________________
Depression__________________________
Asthma or Chest Problems_________________
Alcoholism/Addiction_____________________
Osteoporosis___________________________
Ovarian Cancer _________________________
Cancer Other___________________________
Testicular Cancer________________________
Breast Cancer___________________________
Bowel Cancer________________________
Do you think you eat a healthy diet?____________
Are you vegetarian or on any special diet?_____________
How many times in a week do you do exercise?
What type of exercise ? ____________________________
(Ideally it should last at least 20 minutes and make you breathe harder, sweat or increase your pulse rate)
Have you ever drunk alcohol? If so what?_____________________________________
Do you smoke?
YES / NO
Have you ever smoked?
Would you like help giving up smoking?
YES
/
YES / NO
NO
Have you ever been offered or experimented with illegal drugs?
If YES what?___________________
Do you wish to discuss any sexual Issues________________________________
Please tick any of the following you would like more information, advice or help with
Bullying at school
Persistent cough or wheeze
Loss of Appetite
Addiction of any sort
Recent change in weight
Difficulty swallowing
Sickness
Headaches
Visual problems
Blackouts, fainting or falls
Difficulty passing urine
Genital discharge, rash or ulcers
Unusual tiredness
Skin rashes
Depression or panic feelings
Bereavement
Family problems or divorce
Worries about other family members
Moles changing colour or size
HPV Vaccine for Teenagers
How would you like to receive the information /advice or help
Please indicate by circling the letter IN BRACKETS ie (A)
(A)
By Telephone with : please circle - Dr or Nurse
(If the number you wish to be contacted on is different from your usual no please write it here)
TEL NO _____________________________________________________
(B)
OR
Discussion with a Doctor at the Surgery - I will make an appointment
OR
(C )
Discussion with a Nurse at the Surgery – I will make an appointment
Alternatively you can get further information on the following website www.patient.co.uk
Signature (Of Patient)__________________________ Date_____________
Signature (On Behalf of Patient)__________________ Date______________
(
Relationship to Patient)__________________________________
It is entirely normal for young people to have worries about their health or other life issues from time to time. This is an
opportunity for you to discuss anything you like with our nurse. Please note below what you would like to chat about.
Summary Care Record – your emergency care summary
The NHS in England is introducing the Summary Care Record, which will be used in
emergency care. The record will contain information about any medicines you are
taking, allergies you suffer from and any bad reactions to medicines you have had to
ensure those caring for you have enough information to treat you safely.
Your Summary Care Record will be available to authorised healthcare staff providing
your care anywhere in England, but they will ask your permission before they look at
it. This means that if you have an accident or become ill, the doctors treating you will
have immediate access to important information about your health.
Your GP practice is supporting Summary Care Records and as a patient you have a
choice:
• Yes I would like a Summary Care Record – you do not need to do anything and
a
Summary
Care
Record
will
be
created
for
you.
• No I do not want a Summary Care Record – enclosed is an opt out form.
Please complete the form and hand it to a member of the GP practice staff.
If you need more time to make your choice you should let your GP Practice know.
For more information talk to our Patient Advice and Liaison Service (PALS – 01305
361285), GP practice staff, visit the website www.nhscarerecords.nhs.uk or
telephone the dedicated NHS Summary Care Record Information Line on 0845 603
8510.
Additional copies of the opt out form can be collected from the GP practice, printed
from the website www.nhscarerecords.nhs.uk or requested from the dedicated
NHS Summary Care Record Information Line on 0845 603 8510.
You can choose not to have a Summary Care Record and you can change your
mind at any time by informing your GP practice.
If you do nothing we will assume that you are happy with these changes and create a
Summary Care Record for you. Children under 16 will automatically have a Summary
Care Record created for them unless their parent or guardian chooses to opt them
out. If you are the parent or guardian of a child under 16 and feel that they are old
enough to understand, then you should make this information available to them.
Request for all clinical data to be withheld from the Summary Care Record
Please complete this form and return it to your GP practice
To be completed by the individual (data subject) making the request
Please complete in BLOCK CAPITALS
Title................. Surname ....................................Date of Birth……………………………
Forename(s)..........................................................................
Address................................................................................
………………………………………………………………………………………………………….
Postcode .......................................................
What does it mean if I DO NOT have a Summary Care Record?
NHS healthcare staff treating you may not be aware of your current medications in
order to treat you safely and effectively.
NHS healthcare staff may not be aware of any allergies/adverse reactions to
medications and may prescribe or administer a drug/treatment with adverse
consequences.
If you have any questions, or if you wish to discuss your choices or concerns, please
telephone the NHS Summary Care Record Information Line on 0845 603 8510.
If you remain unsure about whether or not to have a Summary Care Record please
contact your participating practice.
DATE___________________________
EMIS No…………………………….
New Patient 0-15 Child
April
11s
National Health Service Number________________________________________________________
NHS Entitlement i.e. E128 /E112 / E111 /EU ID Card / or other proof of residency
State Document___________________________Seen By ___________________________
SURNAME______________________________________
SCHOOL/COLLEGE________________________________
FORENAME____________________________________
EMPLOYMENT________________________________________
FORENAME____________________________________
WHO IS AT HOME WITH YOU___________________________
CALLING NAME_________________________________
ETHNIC ORIGIN_____________________________________
FIRST LANGUAGE____________________________
TELEPHONE NO______________________________________
ADDRESS___________________________________________________________________________________
POST CODE________________
Precise Place of Birth. Town, County, and Country:
_______________________________
Is this the first time you have registered with a NHS Doctor in the UK: ________________YES/NO
Have you ever resided outside the UK:
____________________________________
YES/NO
Is this the first permanent stay in the UK: ______________________________________YES/NO
If YES - Please give date of arrival in the UK:
_____________________________
Have you returned to this country from abroad:
________________________________ YES/NO
If YES, please give dates when you left the country and returned
Date of Embarkation:
__________________
Date of Return:
_________________
Have you ever been in the armed forces: _______________________________________YES/NO
If Yes give dates of enlistment (Approx) from
_________
__
to
_____________
If you a are a member of service personnel please give details of their rank service number and full
details of your previous SMO
Please give details of all your previous address where you were registered with a NHS Doctor with
approximate dates and Doctors details if known:
Your Address + Post Code
Date
From
Date To
Doctors Name + Address
Signature (of Parent/ Guardian)…………………………………………………………………………..
Date………………………………….
CONFIDENTIALITY
You can be sure that anything you discuss with any member of this practice – family doctor,
nurse or receptionist – will stay confidential.
Even if you are under 16 nothing will be said to anyone – including parents, other family
members, care workers or tutors – without your permission.
The only reason why we might have to consider passing on confidential information without
your permission, would be to protect you or someone else from serious harm. We would
always try to discuss this with you first.
If you are being treated it is best if you allow the doctor or nurse to inform the practice of
any treatment you are receiving.
If you have any worries about confidentiality, please feel free to ask a member of staff.