New Patient Questionnaire – Child (Under 16) Name First Last Date of Birth Day Month Year Gender Male Female Other Please specify Phone NumberEmail Address Enter Email Confirm Email Parent / Carer First Last Parent / Carer Contact NumberDo you take regular medication?Any serious illnesses, operations or admissions?Are you allergic to anything?Ethnicity Group (Please tick the appropriate box)What is your Ethnicity Group?White – BritishWhite – IrishWhite – OtherBlack – BritishBlack – AfricanBlack – CaribbeanBlack – OtherAsian – BritishAsian – IndianAsian – PakistaniAsian – BangladeshiAsian – OtherMixed – White & Black Caribbean Mixed – White & Black AfricanMixed – White & AsianMixed – OtherChineseOtherPrefer Not To SayFirst Spoken Language Name of School / Nursery Summary Care RecordWould you like to have a summary care record? (shared record with healthcare staff) Yes No Please complete our opt-out form separately once you have completed this form. Patient Online AccessAccessing GP services at home, work or on the move 24 hours a day. Includes appointment booking, requesting repeat medication, secure messaging and viewing of medical records. Please speak to a receptionist to register.Immunisations Given DTAP/IPV/HIB (2 months) Optional Prevenar (2 months) Optional Meningitis B (2 months) Optional Rotavirus (2 months) Optional DTAP/IPV/HIB (3 months) Optional Rotavirus (3 months) Optional DTAP/IPV/HIB (4 months) Optional Meningitis B (4 months) Optional Prevenar (4 months) Optional HIB/MenC (12 months) Optional Prevenar (12 months) Optional MMR (12 months) Optional Meningitis B (12 months) Optional MMR Booster (3 months after 1st MMR Optional DTaP/IPV (3 years and 4 months) Optional Please specify date/s and place/s of immunisationsAccessible Information StandardFor patients with a disability, impairment or sensory loss.My information and communication preferences are: Easy Read Optional Large Print Optional BSL Optional Email Optional Text Optional Other Optional Please specify
