Children (8 weeks - 15 years old) - New Patient Registration Form & Questionnaire

Thank you for choosing to register with Adelaide Medical Centre. To ensure your child's registration can be fully completed and that their medical record is kept up-to-date, please complete this form as accurately as possible. Do ensure that you have your child's immunisation history available when completing the form.

Child's Personal Details

TITLE

FIRST NAME (S) *

SURNAME *

PREVIOUS SURNAME (IF ANY)

DATE OF BIRTH *

PLACE OF BIRTH (INCLUDING BOROUGH, IF LONDON *

NHS NUMBER *

ADDRESS *

POSTCODE *

HOME NUMBER

MOBILE NUMBER *

EMAIL ADDRESS

IS THE CHILD REGISTERED DISABLED ?

Yes No

IF YES, PLEASE GIVE DETAILS OF THE DISABILITY:

IS THE CHILD A MAIN CARER? IF YES, PLEASE STATE FOR WHOM?

Child's Ethnicity

ETHNICITY - PLEASE SPECIFY WHICH GROUP YOU CONSIDER YOUR CHILD BELONGS TO *

Arab

Asian / Asian British - Indian; Pakistani; Bangladeshi; Chinese

Other Asian Background - please describe below

Black/African/Caribbean/Black British

Other Black background - please describe below

Mixed / Multiple Ethnic Group - please describe below

White - Scottish/English/Welsh/Northern Irish/British; Irish; Gypsy or Irish Traveller

White Other - please describe below

I do not wish to state

PLEASE DESCRIBE BELOW ANY OTHER ETHNIC GROUP OR BACKGROUND

Parent / Guardian (s) Details

MOTHER'S FULL NAME (SURNAME; FIRST NAME)

FATHER'S FULL NAME (SURNAME; FIRST NAME)

GUARDIAN'S FULL NAME (SURNAME; FIRST NAME), IF APPLICABLE

GUARDIAN'S RELATIONSHIP TO THE CHILD, IF APPLICABLE

PLEASE INDICATE WHO HAS PARENTAL RESPONSIBILITY *

Mother

Father

Guardian

Previous GP

1. NAME AND ADDRESS OF PREVIOUS GP, IF PREVIOUSLY REGISTERED IN THE UK

Next of Kin

PLEASE GIVE NAME, ADDRESS, TELEPHONE NUMBER AND RELATIONSHIP OF NEXT OF KIN *

Contacting You

Please note that Proxy Online Access, to some aspects of the child's medical record can be requested for children under the age of 12. Further information and application can be found on our website.

DO YOU AGREE THAT YOU MAY BE CONTACTED FROM TIME TO TIME, VIA EMAIL AND/OR SMS, WITH PRACTICE NEWS, ADVICE ABOUT MY HEALTH AND/OR APPOINTMENT REMINDERS. *

Yes No

Signature

SIGNATURE *

DATE *

Child's Medical History

ALLERGIES (ANYTHING, INCLUDING MEDICINES)

HAS YOUR CHILD HAD ANY MEDICAL PROBLEMS IN THE PAST NEEDING HOSPITAL, SURGERY ATTENDANCE OR REPEATED VISITS TO THE DOCTOR?

Yes No

ANY CURRENT ILLNESSES FOR WHICH THEY ARE RECEIVING TREATMENT?

Yes No

IF YES, PLEASE GIVE DETAILS:

IS YOUR CHILD TAKING ANY PRESCRIBED MEDICATIONS / TABLETS?

Yes No

IF YES, PLEASE GIVE DETAILS BELOW, INCLUDING DOSE AND FREQUENCY OR INDICATE IF A COPY OF THEIR REPEAT MEDICATIONS CAN BE PROVIDED:

Child's Immunisation History

It is important that we have an up-to-date record of your child's vaccinations to ensure your child is fully immunised in accordance with the UK Immunisation Schedule

Immunisations of Children Aged 12 -15 Years old

Please move to the next section if not applicable

PV - 1ST DOSE GIVEN

HPV - 2ND DOSE GIVEN

TETANUS, DIPHTHERIA AND POLIO TD/IPV - GIVEN AGED 14 (SCHOOL YEAR 9)

MENINGOCOCCAL GROUPS A, C, W AND Y DISEASE MENACWY - GIVEN AGED 14 (SCHOOL YEAR 9)

Family Medical History

IS THERE A FAMILY HISTORY, WITHIN IMMEDIATE FAMILY, OF ANY OF THE FOLLOWING?

Heart Attack, Angina or bypass surgery?

High Blood Pressure

Stroke / TIA

Diabetes

Asthma / COPD

Cancer (if selected, please include details of the site of cancer below

IF ANY OF THE ABOVE SELECTED, PLEASE INDICATE WHICH IMMEDIATE FAMILY MEMBER(S)

Additional General Details

WHICH NURSERY OR SCHOOL DOES YOUR CHILD ATTEND?

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Children (8 weeks - 15 years old) - New Patient Registration Form & Questionnaire

Children (8 weeks - 15 years old) - New Patient Registration Form & Questionnaire

Further Information