Newborn Registration Form & Questionnaire

Thank you for choosing to register with the Adelaide Medicale Centre. Please ensure you complete the details below as accurately as possible.

Child's Personal Details

A copy of your baby's birth certificate will be requested seperately

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:

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

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 HEALTH AND/OR APPOINTMENT REMINDERS. *

Yes No

Signature of Parent / Guardian

SIGNATURE *

DATE *

Newborn - SCID Screening (Heel Prick Test)

Complete if registering baby 0 - 8 weeks old

SCID screening is offered, at the time of the Newborn Heel Prick when baby is 5 days old. Please complete the information below as this will be needed before the baby has their 1st immusnisation.

SCID SCREENING RESULT - A COPY OF THE RESULT WILL BE REQUESTED ONCE BABY HAS BEEN REGISTERED

SCID Condition Not Suspected

SCID Condition Suspected

SCID Screening Undertaken - Awaiting Results

SCID Screening Declined

SCID Screening Not Offered

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:

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)

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Newborn Registration Form & Questionnaire

Newborn Registration Form & Questionnaire

Further Information