New Patient Health Questionnaire for CHILDREN UNDER SIXTEEN Under 16s New Patient Questionnaire PERSONAL DETAILSName Date of birth MM slash DD slash YYYY Previous Surname Optional Place of Birth Address Postcode Previous Address Optional Previous GP Optional Telephone Number OptionalNHS Number (if known) Optional Have you ever registered with this practice before? Yes No Ethnic Origin MEDICAL HISTORYHas you child had any of the following medical problems? Diabetes Optional Asthma Optional Epilepsy Optional Thyroid Problems Optional Has your Child had any other illnesses, accidents or operations? Yes No If yes, please give details OptionalIs your child under the care of a hospital specialist Yes No If yes, please give details OptionalIs your child taking any medicines or tablets at the present time Yes No If yes, please give details Optional**It will be necessary for you to see the general practitioner before you are issued with your first medications from the surgery.**ALLERGIESDoes your child have any known allergies? Yes No If yes, please give details OptionalVACCINATIONS HISTORYHas your child been immunised? Yes No As a baby, if given any of the following, please give approximate dates (these may be in your red rook)Pertussis/Tetanus/Diphtheria/PolioPCVHibMeningitisOther Add RemoveAround 12 months, if given Hib/Menc, what date? Optional Around 13 months, if given any of the following, what date?MMRPCV Add RemovePreschool Boosters: Three years four month to five years old, if given any of the following, what date?Pertussis/Tetanus/Diphtheria/PolioMMR Add RemoveAt Thirteen to Sixteen years old, if given any of the following, what date?Tetanus/Diphtheria & PolioRubellaTBMeningitis Add RemoveSummary Care Record (SCR)The practice participates in the SCR programme. A Summary Care Record is a National electronic record which contains essential medical information for NHS staff to use in an emergency, or when your practice is closed. This only includes information about your medication, allergies and any bad reactions you may have had to medicines. If you are happy for us to make an SCR for your child, you do not need to do anything. If you DO NOT want us to make an SCR for your child, you must complete an OPT OUT form available from reception.Date MM slash DD slash YYYY All new patients are registered with a named GP in the practice. However, this is for administrative purposes only and you may inform the practice if you have a preferred GP within the practice. This information will be recorded, but does not guarantee that you will always be able to see preferred GP