Registration Questionnaire for Children aged 7 years or younger

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KENSINGTON PARK MEDICAL CENTRE
CHILD UNDER 7 YEARS Registration Form
NOTE: This information is strictly private & confidential
ALL QUESTIONS MUST BE ANSWERED - PLEASE PRINT YOUR ANSWERS CLEARLY
Name:
Date of Birth:
NHS Number:
Parent / Guardian Details – Name:
Relationship:
Telephone Number:
Mobile Number:
Email Address:
Do you wish to receive SMS messages and Reminders?
Yes
Would you like Internet appointment booking?
Yes
Would you like Internet Prescription Ordering?
Yes
Would you like Internet Access to your Medical Records?
Yes
□
□
□
□
No
No
No
No
□
□
□
□
How did you hear about the practice: (please tick the box that applies)
Friend
□
Family □
Practice Website □
NHS Choices
□
Other – please state:
Ethnicity: (please tick the box that applies)
□ Brit/Mixed Brit □ Brit/Mixed Brit
□ White Irish
□ White & Asian
□ Other White
□ Other Mixed
□ Wht & Blk Carib □ Indian/Brit India
□ Other – please state
□Pakistani/Brit Pakist
□ African
□ Banglasdeshi/Brit Bangl □ Other Black
□ Other Asian
□ Chinese
□ Caribbean
Main Language Spoken:
Do you need an Interpreter?
Birth Details: Was your baby born?
Yes
□ On time
□ Premature
□
No
□
□ Late
What was your baby’s birth weight (if known)?
Were there any problems during pregnancy/at the birth?
Signed:
(Parent / Guardian)
Date:
Please Turn Over
Previous Medical History:
□
Does your child have any Medical Conditions or have they had any Operations? Yes
No
□
If YES, Please give details of any Medical Conditions/Operations that your child has or has had in the past (include
dates if possible):
*please ask for another sheet of paper if you require more space
No
□
Are you taking any prescribed medications including tablets, inhalers, injections, etc? Yes
If YES: Please provide details:
□
Allergies: Is your child allergic to any Medicines (eg. Penicillin)?
Yes
If YES please provide details of What you are allergic to and the reaction
Name of Medication / Allergy
□
Reaction (if known)
*please ask for another sheet of paper if you require more space
Medicines:
Name of Medication
Strength of Medication
No
□
How often it is taken
*please ask for another sheet of paper if you require more space
Family History: Please give details of any inherited conditions within you family for example any of those
conditions listed above: Please put as much information as possible including which member of your family, what
their condition is and approximate age at diagnosis.
*please ask for another sheet of paper if you require more space
Please Turn Over
Immunisation History:
PLEASE NOTE: This section MUST be completed from your child’s red book or other immunisation records.
IMMUNISATION
DATE GIVEN
BCG (Tuberculosis)
DTaP/Hib/IPV or Pediacel
(Diptheria/Tetanus/Pertussis/Haemophilus Influenza B/Polio)
1st Dose:
2nd Dose:
3rd Dose:
1st Dose:
PCV or Prevenar (Pneumococcal)
2nd Dose:
3rd Dose:
Rotavirus
1st Dose:
Meningitis C
2nd Dose:
1st Dose:
2nd Dose:
Hib/Men C or Mentorix
(Haemophilus Influenza B/Meningitis C)
MMR (Measles/Mumps/Rubella)
Pre School Booster - 3yrs 4mths to 5yrs of age
(DTap/IPV & MMR)
MMR (Measles/Mumps/Rubella) Booster
Please list any OTHER Vaccinations that your child has had and the dates
Vaccination:
Date Given:
Please Turn Over
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