New Patient Questionnaire for Under 16 S
New Patient Questionnaire for Under 16s
Name: / Gender: Male / FemaleTelephone Numbers:
By providing this mobile number I give explicitconsent to receive text messages from the surgery. / NHS Number:
Date of Birth:
Name of School:
Special/educational needs:
For Children Under 5 only please provide the details of his/her former Health Visitor:
Details of any Hospital Admissions or Operations & Dates:
Other Illnesses:
Repeat Medication (including dose and frequency):
Please attach a repeat slip if possible.
Allergies (medicines, food, animal etc):
IMMUNISATION RECORD
To enable us to register your child we must have the dates of the following vaccinations. These may be obtained
from your child’s red book or by contacting your previous Health Visitor/doctor’s surgery. (Please state dates given)
1st / 2nd / 3rd / Booster / Booster
Diphtheria, Tetanus, Polio and Hib DTaP/IPV/Hib
Pneumococcal (PCV)
Rotavirus
Meningitis C
(Men C)
Hib/Men C
Measles, Mumps, Rubella (MMR)
Diptheria, Tetanus, Pertussis and Polio (dTaP/IPV)
HPV (cervical cancer vaccination)
Girls 12-13 only
Tetanus, Diphtheria and Polio (Td/IPV)
Ethnicity: / Main Language Spoken: / Interpreter required: Yes / No
For Children over 15
Do you smoke: Yes / No / If so, how many per day?
If you are a smoker and would like help to stop, please ask for information about local smoking cessation services. Please tick to confirm you have read this information [ ]
NHS ORGAN DONOR REGISTRATION
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissues may be used for transplantation after my death. Please tick the boxes that apply
Any of my organs or tissues [ ]
Kidneys [ ] Heart [ ] Liver [ ] Corneas [ ] Lungs [ ] Pancreas [ ] Any part of my body [ ]
Signature confirming my agreement to organ/tissue donation ……………………………………………………… Date ……………………
For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk or call 0300 1232323
SUMMARY CARE RECORDS
The NHS is changing the way your health information is stored and managed. The NHS Summary Care Record is an electronic record of important information about your health. It will be available to heath care staff providing your NHS care. If you require more information please ask at reception or visit http://systems.hscic.gov.uk/scr
Are you happy to have a Summary Care Record? Yes / No / More time required
Parent/Guardian Name:
Parent/Guardian Contact Number: Relationship to Patient:
Home:
Mobile:
I would like to receive appointment reminders and other relevant text messages on this number
(Delete if you do not wish to receive text messages from Annandale)
Signature of patient: ……………………………………… OR Signature on behalf of patient: ………………………………………………
Date: ……………………………………