NOTTING HILL MEDICAL PRACTICE

Under 16 years

Dr Doran, Dr Downey, Dr Cubitt, Dr Mulholland, Dr Monaghan, Dr Burrows, Dr Martin

Welcome to Notting Hill Medical Practice

New Patient Questionnaire

(All answers are in confidence)

This practice does not discriminate on the grounds of race, gender, social class, religion, sexual orientation, appearance, disability or medical condition.

Please attach this Questionnaire to your Medical Card/HS22X form when presenting to the Practice

As a patient joining Notting Hill Medical Practice we require the following questions to be answered to allow an accurate account of your child’s medical history..

Surname / First Name
Date of Birth / Place of Birth
Address including Postcode / Telephone Home
Mobile Number
Next of kin:
Previous Doctor Name & Address - We may need to contact your previous doctor to provide continuity of care:

Family History:

Please indicate below if any of the listed relatives have suffered from any of the following conditions

Grand
Mother / Grand
Father / Mother / Father / Aunt / Uncle / Sister / Brother
Cancer
Diabetes
Epilepsy
Heart Disease
Stroke
Other(please indicate)

IMMUNISATION HISTORY – Please either fill this in or bring the child’s red book/immunisation record to your new patient medical

My child has had the following injections:

1st Vaccinations / Date: / MMR 1 / Date:
2nd Vaccinations / Date: / 5 year Booster MMR 2 / Date:
3rd Vaccinations / Date: / Other / Date:
Pre-school Booster / Date:

Does your child have any Allergies – If Yes please list

Please list any medication that are currently taking

Please list ALL medications that you may need to request from the practice. If medicine is not on this list, this can lead to delays in prescriptions being issued.

Please list any Operations with Dates (if known)

If your child is currently attending hospital for any medical conditions please list

Hospital / Consultant/Department / Problem that you are attending hospital for / Date last seen

Please let us know if any of the following Health & Social Care Professionals are involved with your child at present

Yes / No / Name/Contact Details
Physiotherapist
Occupational Therapist
Social Worker
Specialist Nurse
Child & Adolescent Psychiatry
Speech Therapy
Educational Psychology
Other

If your last GP was within Northern Ireland, we can access the record of your medication on line via the Electronic Care Record. We can also use this to look up hospital letters and investigations prior to receiving your notes.

The electronic record will only be looked up if we have your permission to do so and if it is clinically necessary.

Please sign to indicate if you do or do not give your permission.

I (select appropriate) give/do not give permission for my child’s electronic care record to be accessed to ensure my new GP practice has all necessary and relevant medial information.

Signed by person with parental responsibility: ______

Confidential: New Registration Form Children under 6 years Page 1 of 2