New Patient Questionnaire (14 and under) New Patient Questionnaire – Under 14 Name First Name Surname Any previous First Names Optional Any previous Last Names Optional Date of Birth Day Month Year Place of Birth Optional Mobile Number (Guardian/Carer)Home Phone Number OptionalMain Spoken Language Sex Current Address Street Address Address Line 2 City Postcode Do you have a previous address? Yes No Previous Address Street Address Address Line 2 City Postcode Have you recieved care at another GP surgery before registering with us? Yes No Name of Previous Doctor Address of Previous Doctor Street Address Address Line 2 City Postcode While Registered at your previous GP did you receive care from a "Health Visitor"? Yes No Name of previous Health Visitor Name of Current School Address of current school Street Address Address Line 2 City Postcode Have you been enrolled at any other schools before? Yes No Name of previous school Optional Address of previous school Street Address Optional Address Line 2 Optional City Optional Postcode Optional Parent/Guardian DetailsName First Name Surname Relationship to child Optional Contact NumberEmail Address Enter Email Confirm Email Do you live at a different address to the child? Yes No Current Address Street Address Address Line 2 City Postcode Would you like to declare another Parent/Guardian? Yes No Name First Name Surname Relationship to child Contact NumberEmail Address Enter Email Confirm Email Do you live at a different address to the child? Yes No Current Address Street Address Address Line 2 City Postcode What is the child's ethnic originPlease Select…EnglishWelshScottishNorthern IrishBritishIrishGypsy or IrishTravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed / Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black / African / Caribbean backgroundArabPrefer not to sayOther (Please Specify)Summary Care RecordHave you received information on the Summary Care Record? Yes No (SCR is where your basic medical history is shared with hospitals across England in case of an Emergency)Do you wish to opt out? Yes No (i.e. not let any information about you be available to hospitals, A&E or Out of Hours, if needed)Communication ConsentDo you consent to us contacting you by text and/or email about your child? Yes by text and email Optional Yes by email only Optional Yes by text only Optional No Optional Under the Data Protection Act we have to inform you that the contents of any e-mails will not be confidential and secure. Any information we obtain from you will be used only for us to communicate with you. This information will not be passed on to any third party and will not be kept for longer than necessary. Confidentiality and security cannot be guaranteed whilst in transit and all e-mails should contain the minimum of identifiable information. Any e-mails you send will be stored on your e-mail provider’s server and should be deleted as soon as possible as the NHS have no control over these mail servers. PLEASE NOTE: YOU CAN VIEW OUR PRIVACY NOTICE ON OUR WEBSITE: www.wyreforesthealthpartnership.co.ukMedicationDo you take any regular medications? Yes Optional No Optional If 'yes', please provide detailsNote: If you have nominated a specific pharmacy for your prescriptions you may need to change this to a more local pharmacy.AllergiesDo you have any allergies to any drugs, food or other substances? Yes No If 'yes', please provide detailsDo you need to carry an adrenaline pen? Yes No Family HistoryHave you, your parents, siblings suffered with any of the following? Asthma/COPD Heart Attack/Heart Disease Mini Stroke/Stroke/TIA Epilepsy High Blood Pressure Diabetes Glaucoma Cancer Kidney Disease Depression/MentalHealth problems Learning Difficulties Thyroid problems Osteoporosis Atrial Fibrillation Dementia Other (please Specify) No If you checked any of the above, please provide details(Please specify what condition, which family member and when they were diagnosed)If 'Other', please specify(Please specify what condition, which family member and when they were diagnosed)Hospital CareAre you currently under Hospital Care? Yes No Hospital Name Nature of problem Consultant (If known) (if unknown, state “Unknown”)ImmunisationsAre your childhood immunisations up-to-date? Yes No (DTP, Polio, Meningitis, Hib, Pneumococcal, MMR, Rotavirus)In ClosingPatients should provide proof of identification and proof of address when registering. To register a child under-14 the parent/carer will be asked to show the birth certificate to complete the registration process. This information will only be used by doctors and staff of the Medical Centre and will be treated with confidentiality.Signature (Guardian’s Full Name)Comments OptionalThis field is for validation purposes and should be left unchanged.