New Patient Questionnaire Children (aged 0 – 16 years old) Please upload birth certificate/proof of guardianship. Please also provide copies of immunisations (if aged under 5) * Drop files here or Select files Max. file size: 50 MB. Background Details Your Child’s DetailsTitlePlease SelectMrMsMrsMissMxNHS Number First Name First Surname Last Gender Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberParent or Guardian DetailsYour Name Relationship to Child Address Street Address Address Line 2 City Postcode Home Telephone OptionalWork Telephone OptionalMobile TelephoneDo you consent to be contacted by SMS? Yes No Email Do you consent to be contacted by email? Yes No Family Registered with Us OptionalOther Details Previous GPName of Previous GP Address Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Childs Other DetailsCountry of Birth Ethnicity White (UK) White (Irish) White (Other) Black Caribbean Black African Black Other Bangladeshi Indian Pakistani Chinese Other Religion C of E Optional Catholic Optional Other Christian Optional Buddhist Optional Hindu Optional Muslim Optional Sikh Optional Jewish Optional Jehovah’s Witness Optional No Religion Optional Other Optional Is your child an Overseas Visitor? Yes European Health Insurance Card Held (please bring details with you) No Do you have any family members in the Armed Forces? Yes No Please give details of family members who are in the Armed Forces:Communication Needs LanguageWhat is your childs main spoken language? Do you need an interpreter? Yes No CommunicationDoes 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 Learning DisabilityDoes your child have a Learning Disability? Yes No (If yes please request a Learning Disability Screening Tool form)Medical HistoryHas your child suffered from any of the following conditions? Asthma Optional COPD Optional Epilepsy Optional Heart Disease Optional Heart Failure Optional High Blood Pressure Optional Diabetes Optional Kidney Disease Optional Stroke Optional Depression Optional Underactive Thyroid Optional Cancer Optional For Cancer, please specify which type Any other conditions, operations or hospital admission details: Optional If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional Family 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 AllergiesPlease record any allergies or sensitivities below Optional Current MedicationPlease check and include as much information about your child’s current medication below.If they have a previous repeat medication list please give this to us and they may need a medication review appointment: OptionalFurther Details Electronic PrescribingIf you would like your child's prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional Parent or Guardian Signature Optional Please provide your full nameSharing Your Childs Health RecordDo you consent to your GP Practice sharing your child's health record with other organisations who care for you? Yes (recommended) No – Never Do you consent to your GP Practice viewing your child's health record from other organisations that care for you? Yes – (recommended) No Your Childs Summary Care Record (SCR)Do you consent to your child having an Enhanced Summary Care Record with Additional Information? Yes – (recommended) No Parent or Guardian Signature Please provide your full nameDate Day Month Year Name OptionalThis field is for validation purposes and should be left unchanged.
