Personal Details Title ---MrMrsMissMsDrMaster Gender ---MaleFemale Given Name Family Name Previous Surnames (If any) Date of birth NHS Number Town and city of Birth House Name/Flat Number Street/Road name Town/City Post Code Home Phone Email Next Help us tract your medical records Your previous address in the UK Your previous address in the UK Address of you previous GP If you are from abroad Your first UK address where registered with a GP If previous resident in the UK, date of leaving Date you first came to the UK Were you ever registered with Armed Forces GP Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas: RegularReservistVeteranFamily Member (Spouse, Civil Partner, Service Child) Address before enlisting Post Code Service or Personnel number Enlistment date Discharge date (if applicable) Footnote: These options are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority charities services If you need your doctor to dispense medicines and appliances* *Note: Not all doctors are authorised to dispense medicines I live more than 1.6kn in a straight line from the nearest chemistI would find it difficult getting them from a chemist BackNext NHS Organ Donor registrations NHS Organ Donor Donation YESNOI want to register my details on the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. NHS Blood Donor Registration NHS Blood Donor Registration YESNOI would like to join the NHS Blood Donor register as someone who may be contacted and would be prepared to donate blood. BackNext Registration Health Questionnaire – Children 0-16 We may not receive your child’s records for some time so please would you help us by filling out this form? It is really important that we know if they have had any illnesses, or are on treatment/ medication. If you are not sure of the answer to anything, just put “Don’t know”. Surname Forename(s) Preferred calling name Date of birth Gender ---MaleFemale Mobile number/Parent's mobile Email/Parent's email: Country of birth Main language Interpreter required YesNo 0-5 years old only Were there any problems at birth or during the pregnancy? YesNo If yes please give details The only other parts of this form that must be completed for this age group are the immunisation and ethnicity sections, but you may complete other sections if you wish. Child questionnaire continued Do you have any concerns about your child you would like to discuss at the moment? YesNo If yes, please give details, or ask Reception for an appointment to be made Please give details of any serious illnesses / operations / stays in hospital, with approximate dates Any other inherited condition Is your child taking any regular medication? YesNo If yes, please state what the treatment is for, and name and dose of drug if known: (or you can ask the previous surgery for a print out of your child’s medication) Does he/she have any allergies to medicines, pollen, dust, animals, or any foods? YesNo If yes, please give details and state if the child has an Epipen Has / does a close relative (parent, brother, sister, uncle, aunt) ever suffered / suffer from asthma? YesNo If yes, which relative? Child's weight Child's height Health Visitor Clinics Our Health Visitors run a drop in clinic on Thursdays at Thurleigh Road from 2pm-3.30pm. Letters are sent out to parents by the Health Visitors inviting them to book an appointment elsewhere for the one year review. 15-16 years old only Do you smoke? YesNo If yes, how many cigarettes a day on average? Have you ever smoked? YesNo If yes how much did you smoke and when did you give up? BackNext Child Immunisations We need to have an up-to-date record of your child’s immunisations. Please bring to the surgery • a print out of their immunisation history from their previous practice OR • your child’s RED BOOK We need to have an up-to-date record of your child’s immunisations history. Please complete the details of the date and type of immunisation(s) received: Children immunised outside the UK: Immunisation schedules differ from country to country, but vaccines given are mostly the same – please bring any immunisation records you may have with you when you register your child. Please complete the details of the date and type of immunisation(s) received: If your child needs any immunisations, please make an appointment with a Practice Nurse. If you have any questions about childhood immunisations, please make an appointment to discuss them with a doctor or Practice Nurse – or ask the Health Visitor at the drop in Baby Clinic. Immunisation Consent Please note that consent is required from the parent/guardian each time a child has an immunisation. If you are accompanying the child, consent can be given verbally at the appointment. Unless you accompany your child for their injections, you must send in a handwritten letter with the accompanying adult, or we will be unable to give the child their immunisations. Ethnic Group We are being asked by the Department of Health to record the ethnic group of all our patients, as government wants to make sure there is no discrimination against any ethnic group (Race Relations Amendment Act 2000). You do not have to tell us your ethnic group if you do not want to – just tick the “Not stated” box. ---BritishCaribbeanWhite & Black CaribbeanWhite BritishAfricanWhite & Black AfricanOther Black BackgroundIrishWhite IrishWhite & AsianOther White BackgroundPakistani / British PakistaniOther Mixed BackgroundBangladeshi / British BangladeshiChineseBritish /Mixed BritishIndian / British IndianOther Ethnic GroupOther Asian BackgroundNot Stated All information given in this form will be treated in the strictest confidence BackNext Summary Care Record If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. Your options are outlined below; (please indicate your choice). Express consent for medication, allergies and adverse reactions onlyExpress consent for medication, allergies, adverse reactions and additional informationExpress dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care BackNext Accessible Information Standard/h4> Does your child have any special communication requirements/require specific communication support? Sign languageBritish Sign LanguageMakaton sign languageTadoma sign languageLip readingManual or electronic note takerSpeech to text reporterDeafblind intervenerLoop systemUse of a Personal Communication PassportOther If other please state here: What is the best way to send you information? TelephoneText relaySMSLetterEmailOther If other please state here: If you do not wish to receive text messages for appointment reminders please tick here Do you need the assistance of a Communication Professional? Interpreter for Deafblind PeopleBSL InterpreterMakaton InterpreterTadoma InterpreterLipspeakerNote takerSign Language TranslatorSpeech to text ReporterOther If other please state here: Identification Please upload proof of identification of the Child that that application is being made for. This can include passport or ID card so as we can verify their identity. (File types accepted .png, .jpg and .pdf. Maximum file size 5mb) Confirmation and signature Print name of signatory: Back
