3 Queen Street, Wellingborough, NN8 4RW
Tel: Visits 01933 234905 Appointments/enquiries: 01933 234900
Please complete this confidential questionnaire (one for each child to be registered with the practice)
Personal information:
Full name: / ‘Phone - Home: ………………………………………………
Work: ……………………………………………….
Mobile: …………………………………………...
Date of birth:
Next of kin/emergency contact: ………………………………………
Religion:
5No religion / 5Church of England / 5Catholic / 5Other Christian (Specify):5Buddhist / 5Hindu / 5Jewish / 5Jehovah’s witness / 5Muslim / 5Sikh
5Other religion not listed above (Specify):
------
Ethnic origin (select one):
5White (UK) / 5White (Irish) / 5White (Other) / 5 Asian5 Indian/Brit. Indian / 5Chinese / 5Pakistani/British Pakistani / 5Bangladeshi/British Bangladeshi
5Other Asian background / 5African / 5Caribbean / 5 Other black background
5Other mixed background / 5Other
5Ethnic category not stated
------
Main or first language spoken / understood (select one):
5 English / 5 Hindi / 5 Gujurati / 5 Urdu5 Bengali/Sylheti / 5 Punjabi / 5 Polish / 5 Ukrainian
Other (please specify):
Will you require an interpreter to be booked when you visit the surgery? YES/NO
------
Does the child have any special needs – cultural/religious, sight,speech or hearing impediments, mobility, etc. Please attach brief details separately YES/NO
FAMILY HISTORY
Is there a family history of any of the following? (Tick box) / Relationship – mother, father, sister etc to the family member5 Heart disease (eg Angina or Heart Attack) - Diagnosed before age 60 5 After age 60 5
5 Stroke
5 Diabetes
5 Asthma
5 Hypertension
5 Epilepsy
5 Thalassaemia
5 Sickle cell
5 Cancer - Please indicate site (eg Breast, Prostate, Ovarian, Bowel). Site:
If you have Asthma:
In the last month, have you had difficulty sleeping due to your Asthma symptoms (including coughing)? YES / NO
Have you had your usual Asthma symptoms (cough/wheeze/chest tightness/shortness of breath during the day? YES / NO
Has your Asthma interfered with your usual daily activities (Play/school) YES /NO
------
Medical background - Current medication/allergies/ medical problems
We need to know if the child is currently taking any medication, has any allergies or medical problems. Please list belowand continue overleaf if necessary. If none, state none.
------
Do you have, or have you ever had a Social Worker involved with your family? Yes / No
------
Name of the school/nursery the child is attending? ……………………………..
Height: …………….. Weight:…………………….
Non-smoker Ex-smoker Current smoker (please tick one box if aged 14 or over)
Summary care record (for information see: www.nhscarerecords.nhs.uk)
If you do not wish to have a Summary Care Record (SCR) automatically created for you tick here
You may elect to add additional information to your SCR by ticking here
SMS text messages
We will offer a free appointment reminder service, if you do not wish to receive SMS messages, please tick here
(Remember to provide a mobile number in the space on page 1)
Online services
Children aged under 16 may register for online services if they are deemed by a GP to be competent to make decisions on their own. Those aged 16 or over are deemed to be adult. Parents with younger children may register their children and request proxy access on behalf the child. Tick the box for a registration application form
------
Electronic prescriptions
For more information see: http://www.connectingforhealth.nhs.uk/systemsandservices/eps/patients
From September 2013, we will be able to send a prescription electronically to the pharmacy of your choice. We are encouraging our patients to consent to having their prescriptions sent electronically to their preferred pharmacy. If you prefer a paper prescription and do not wish to have your prescriptions sent electronically, please tick here . For more information about electronic prescriptions, see our website.
Choice of pharmacy
Which pharmacy would you prefer to use to collect a prescription or have your electronic prescription sent to? Tick one.
Pharmacies are listed in distance from Albany House order (closest first).
3Q 5 Cohens (Herriotts Lane) 5 Cohen’s (Mannock) 5 Cohen’s (Gold street) 5 Superdrug 5 Boots 5 Co-op 5 Tesco 5 Berrymoor 5 Lloyds 5 Rowlands 5 Redwell 5 Croyland (Wollaston) 5
For more distant pharmacies, see NHS Choices (www.nhs.uk)
------