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
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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
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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
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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
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New patient questionnaire pack - CHILD
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