New Patient Questionnaire Form Under 16 Required InformationName First Last Date of Birth Day Month Year NHS No (if known) Optional Gender Female Male Unspecified Email Address Enter Email Optional Confirm Email Optional Contact Number OptionalTown & Country of birth: SMS/Text Consent We will use this to send appointment reminders and health promotion details. Please tick here if you do not wish to receive messages from us OptionalCurrent Address Street Address Address Line 2 City Postcode Previous Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional If from abroad, the date of entry to the UK Day Optional Month Optional Year Optional Previous GP (name of doctor and/or surgery name) OptionalHas the child lived outside the UK? Yes No Date of leaving the UK Day Month Year Date of return Day Month Year About You (Parent or Guardian)Name of adult registering the child First Optional Last Optional Relationship to Child Optional Are you registered or registering at this practice? Yes Optional No Optional Parent/Guardian's Full Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional How would you like us to contact you about your child? OptionalLetterEmailTextPhoneWho has legal parental responsibility? OptionalMotherFatherBothOtherPlease specify Contact NumberDo you consent to be contacted by SMS? Yes No Email Enter Email Confirm Email Do you consent to be contacted by email? Yes No Next of Kin / Name of person(s) with legal parental responsibilityName First Optional Last Optional Contact Number: OptionalDate of Birth Day Month Year Gender Male Optional Female Optional Other Optional Relationship to child Optional Name of school/nursery attended Optional Is your child home educated? Yes Optional No Optional Please list other residents at your home. Are they registered with us? OptionalPlease state name, relationship to child & if they are registered with usPrivate Caring ArrangementsIs your child being looked after by a friend, neighbour in their home? Yes Optional No Optional Is this a private fostering arrangement? Yes No Unsure Please ask reception if you are unsureIf yes, how long have they been living there? Is someone looking after your child at home? Yes No Please let us know if a family member, friend or neighbour helps to look after your child. Carer’s Name First Optional Last Optional Carer’s Contact Number OptionalCarer’s Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Relationship to you Optional Please tick if your child is currently Homeless Optional A refugee Optional An asylum seeker Optional Is your child currently housebound? Yes Optional No Optional If housebound, please provide details:Is the child a ‘child looked after’ under the care of the local authority? Yes Optional No Optional Name of responsible Local Authority Name of social worker First Last Name of Foster Carer First Last If Child ‘looked after’ Delegated Authority documentation needs to be shared with practice Share details with practiceIs your child or family currently involved with Children’s Social services or have they ever been known to Children’s Social services or the safeguarding team? Yes Optional No Optional Name of social worker First Last Please give further details.Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:Your Child’s Ethnic Origin OptionalBlack Caribbean/BritishBlack African/BritishOther Black BackgroundWhite (UK)White (Irish)White (Other)Pakistani/British PakistaniIndian/British IndianBangladeshi/British BangladeshiOther Asian BackgroundOther Mixed BackgroundArabicChineseI do not wish to state my child’s ethnic groupOtherPlease specify What is your childs main spoken language? Do you need an interpreter? Yes No Communication NeedsDoes your child have any communication needs? Yes No Please specify Hearing aid Lip reading Large print Braille British Sign Language Makaton Sign Language Guide dog Other Looking after a family member/carerPlease let us know if your child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs, or substance misuse.Is your child looking after someone at home? Yes Optional No Optional Who is your child looking after? Do you think they would like additional support as a young carer? First Choice Second Choice Third Choice Is your child known to services such as young carers? Yes No Your Child’s Medical BackgroundPlease give information about any serious illnesses, operations, or injuries your child has had in the past? OptionalPlease state the condition, year diagnosed and if it is ongoingIs your child registered with a dentist? Yes Optional No Optional To find a dentist visit NHS Choices www.nhs.ukPlease provide details of any medication your child takes (including the contraceptive pill): OptionalPlease state the name of medication, dosage & frequency Please give details of any allergies or sensitivities your child may have to medication/food OptionalFamily HistoryPlease record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.Medical problem Asthma Optional COPD Optional Epilepsy Optional Heart Disease Optional Stroke Optional Blood Pressure Optional Diabetes Optional Kidney Disease Optional Liver Disease Optional Depression Optional Thyroid Optional Cancer Optional Other Optional For Other please specify below Optional Relative Father Optional Mother Optional Brother Optional Sister Optional Grandmother Optional Grandfather Optional Extended Family member (Aunt/Uncle/Cousin) Optional Immunisation HistoryWhich vaccinations has your child had? Optional1st Diphtheria, Tetanus, Pertussis (Age: 2 months)1st Polio (Age: 2 months)1st HIB, Hep B (Age: 2 months)1st Pneumococcal Vaccine (Age: 2 months)1st Rotavirus (Age: 2 months)1st Men B (Age: 2 months)2nd Diphtheria, Tetanus, Pertussis (Age: 3 months)2nd Polio (Age: 3 months)2nd HIB, Hep B (Age: 3 months)2nd Rotavirus (Age: 3 months)3rd Diphtheria, Tetanus, Pertussis (Age: 4 months)3rd Polio (Age: 4 months)3rd HIB, Hep B (Age: 4 months)2nd Pneumococcal Vaccine (Age: 4 months)2nd Meningitis B (Age: 4 months)Hib/Men C Booster (Age: 12 -13 months)MMR (Measles, Mumps, Rubella) (Age: 12 -13 months)3rd Pneumococcal Vaccine (Age: 12 -13 months)Meningitis B Booster (Age: 12 -13 months)MMR Booster (Measles, Mumps, Rubella) (Age: From 3yrs 4 months)Pre-School Booster Diphtheria, Tetanus, Pertussis & Polio (Age: From 3yrs 4 months)Cervical Cancer (Girls) (Age: 12-13yrs)Tetanus, Diphtheria, Polio ACWY Meningitis (Age: Teenage Booster)Please indicate the date (DD/MM/YY), GP Surgery & if it was done private or abroad.Your Child’s Pharmacy ServicesPrescriptions for your child can be sent electronically to a pharmacy. Please provide the name and postcode of the pharmacy you would like to use for your child. OptionalSharing your child’s medical recordMedical Record Sharing allows your child’s complete GP medical record to be made available to authorised healthcare professionals involved in their care. You will always be asked your permission before anybody looks at your child’s shared medical record. I do not want to share my child’s GP record locally OptionalSummary Care Records contains details of your child’s key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughout England. You will always be asked your permission before anybody looks at your child’s Summary Care Record. I do not want your child to have a Summary Care Record OptionalThe Integrated Care Programme Collates information about your child and the care they receive. It links information from all the different places where your child receives care, such as their GP, hospital and community services, to help them provide a full picture of your child’s medical needs and the care they are receiving. This data is made available to NHS Commissioners so that they can design integrated services and is shared with third parties for research purposes. I wish to OPT OUT from my child’s Personal Confidential Data being shared outside their GP practice OptionalParent/Guardian permission givenPermission given for someone other than a Parent/Guardian to accompany your child to an appointment? E.g. Grandparent, Nanny, childminder Yes Optional No Optional Name of person(s): First Optional Last Optional Thank you for completing this form Please see our practice leaflet/website for further information about our team/services.Name OptionalThis field is for validation purposes and should be left unchanged.