Packers Surgery. Questionnaire for Children aged under 16 years old

Transcription

1 Packers Surgery Questionnaire for Children aged under 16 years old Please use a ballpoint pen and write in BLOCK CAPITALS. You have just joined our list and it could take some weeks before your records reach us. The information given here might be important and the absence of these records may impair the service, which we wish to give you. Therefore, it is in the interests of both you and your doctor to fill in this questionnaire. DATE: First name(s): Address: Post code: Telephone no: Date of birth: Mother s surname (if different from child): Next of Kin: Relationship to you: Contact Number: Allergies: Has he/she ever been allergic to any medicines, or suffers a reaction to pollen or animals? If so please give details: 1

2 I confirm that I give consent for my parents/guardian to have access/discuss my medical records. My details Title: Mr / Miss / Other Forename(s): Date of Birth: Current postal address: Post Code: Telephone No: Mobile No (for text messaging service): Parent/Guardian Details Title: Mr / Mrs/ Miss / Other Forename(s): Signed. Date. 2

3 Personal medical history: Has he/she ever suffered from any serious illnesses, disabilities or had any operations? Please mention if there were any complications at birth: YEAR: DETAILS: Medication: Is he/she taking any tablets, medicines or using any inhalers at present? If so please list: Family History: Has any first-degree relative (parent/brother/sister) died before the age of 65? If so, please give details: Person deceased Age Cause of death 3

4 CHILD IMMUNISATIONS FORM IMMUNISATIONS Bacille Calmett Guerin (BCG) DATE GIVEN 1 st Hepatitis B 2 nd Hepatitis B 3 rd Hepatitis B 1 st Pediacel (Diptheria/Tetanus/Acellular Pertussis 1 st Prevenar (Pneumococcal) 2 nd Pediacel (Diptheria/Tetanus/Acellular Pertussis 1 st Men C Meningococal C 3 rd Pediacel (Diptheria/Tetanus/Acellular Pertussis 2 nd Prevenar (Pneumococcal) 2 nd Men C Meningococal C Men C (Meningococcal C) and Hib Booster (Haemophilius Influenza b 1 st MMR (Measles/Mumps/Rubella) & Prevenar (Pneumococcal) At 12 months and 13 months Pre-School booster (diphtheria or low dose Diphtheria/Tetanus/Acellular Pertusis/Inactivated Polio Mylelitis Vaccine, MMR 2 at 3-5 years (Measles/Mumps/Rubella) Hib booster at 3-5 years (Haemophilus Influenza b) 1 st HPV (Human Papillomavirus) at years 2 nd HPV (Human Papillomavirus) at years 3 rd HPV (Human Papillomavirus) at years DT/IPV (low dose Diptheria, Tetanus, Inactivated Polio Myelitis vaccine booster) at years 4

5 Ethnic Origin The Department of Health and the Primary Care Trust (PCT) has asked us to record the ethnic origin of all new patients. This information will be added to your medical record. Everyone belongs to an ethnic group, so all our patients are being asked to describe their ethnic group. We are collecting this information to help the NHS to Understand the needs of patients and service users from different groups and so provide better and more appropriate services for you. Identify risk factors some groups are more at risk fo specific diseases and care needs, so ethnic group data can help treat patients and support service users by alerting staff to high-risk groups. If you do not wish to provide this information, please tick the I do not wish to give this information box at the end of the list. White British White Irish Other white background Mixed White and black Caribbean Mixed White and black African Mixed White and Asian Other mixed background Asain or Asian British Indian Asain or Asian British Pakistani Asain or Asian British Bangladeshi Other Asian background Black or Black British Caribbean Black or Black British African Other Black background Chinese Other ethnic background I do not wish to give this information Thank you for taking the time to fill in this questionnaire. Please return this questionnaire together with the other registration form, as we cannot register you until we has been returned. 5