Biddlestone Health Group

BIDDLESTONE HEALTH GROUP

CHILD HEALTH QUESTIONNAIRE

PERSONAL DETAILS

Name…………………………………… / Date of Birth……………………………
Ethnic Origin…………………………… / First Language…………………………
Fathers Name…………………………. / Mothers Name…………………………

SUMMARY CARE RECORD

Do you give us consent to creating your Summary Care Record YES / NO

(See practice brochure for details)

ENHANCED DATA SHARING

Do you give us consent to creating your Enhanced Data Sharing Record YES / NO

(See leaflet for details))

ACCESSIBLE INFORMATION

We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know.

We want to know if you need:

·  information in braille, large print or easy read. YES / NO

·  a British Sign Language interpreter or advocate. YES / NO

·  if we can support you to lip-read or use a hearing aid or communication tool. YES / NO

·  an interpreter YES / NO

ON-LINE ACCESS

This enables patients to currently book appointments and order repeat prescriptions on line. If you would like to use this service we will post out your user name and password after we have registered you as a patient. YES / NO

Please confirm your email address for online access

Email ……………………………………………………………….

SMS MESSAGING

Do you give us consent to send a SMS message to your mobile to remind you of your appointment/results/special clinics etc? YES / NO

Mobile Number…………………………….

ELECTRONIC PRESCRIBING

We are now able to send prescriptions electronically to the majority of chemists in this area and anywhere in England. Would like us to do this? YES / NO

If you would like to nominate a chemist please enter it below:

Nominated Chemist.……………………………………

NEXT OF KIN

Name…………………………………… / Landline Number…………………………….
Mobile Number…………………………….

SMOKING (if child is between the age of 15 – 18)

Do they smoke? YES / NO / If yes, how many per day? ...... PTO
We have stop smoking advisors would you like to see one YES / NO
Please contact the surgery if you would like to arrange an appointment on 265 5755

ALLERGIES & SENSITIVTIES

Details
Allergies
Medicines you are unable to take

FAMILY HISTORY

Is there any of the following in your family (father, mother, brother, sister) before the age of 65 had the following?

Heart Disease (heart attack, angina) / YES / NO
Which family member? ……………….
Stroke / YES / NO
Which family member? ……………….
Cancer / YES / NO
Which family member? ……………….
Site of Cancer / …………………………………..

VACCINATIONS

NAME OF VACCINATION / DATE GIVEN
Diphtheria/Tetanus/Pertussis/Polio & Hib
Pneumococcal
Diphtheria/Tetanus/Pertussis/Polio & Hib
Meningitis C
Diphtheria/Tetanus/Pertussis/Polio & Hib
Pneumococcal
Meningitis C
Hib & Meningitis C
MMR
Diphtheria/Tetanus/Pertussis/Polio
MMR
Tetanus, Diphtheria & Polio

CURRENT MEDICATION

NAME / HOW OFTEN / DOSE / HOW LONG ON MEDICATION?

DETAILS OF NURSERY OR SCHOOL

Name / Address / Telephone Number