Nightingale Practice New Patient Questionnaire - Child 0-14 Years

A form for parents or carers registering their child with the practice for the first time.

Last Updated: 12/03/2021

Child's personal details

Please try and complete this questionnaire in full to give your new doctor any important information about your child’s health. All information will be kept strictly confidential.

First name/s *

Surname *

Date of Birth *

Address *

Post code *

School

Child's NHS Number

Previous address & postcode (if you have recently moved)

Parent/Guardian Details

Name *

Relationship to child *

Home telephone

Work Telephone

Moble phone

E-mail

Ethnicity

Please select the ethnic group which most closely matches your ethnicity. This information is used to plan provision of our services e.g. advocacy services.

Ethnicity: *

If you answered 'Other', please specify

Medications

Does your child take any regular medication *

Yes No

If yes, please list medications taken

Are you allergic to any medications?

Yes No

If Yes, please list allergies to medications

Immunisations

For children under 7 years please bring the red book to reception when first visiting

Previous GP name (if applicable)

Previous GP Address

Does Mother/Father or household member have history of Hepatitis B? *

Yes No

Has your child been given any of the following Immunisations? (leave blank if not sure)

BCG (due at 6 weeks)

DtaP/IPV/Hib and PCV (due at 2 months)

DTaP/IPV/Hib and Men C (due at 3 months)

DTaP/IPV/Hib Men C and PCV (due at 4 months)

Hib/Men C (due at 12 months)

MMR and PCV (due at 13 months)

DTaP/IPV or DTaP/IPV and MMR (3-5 years)

Any comments about dates when immunisations were given, if you are unsure etc.

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Nightingale Practice New Patient Questionnaire - Child 0-14 Years

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