New Patient Health Check Questionnaire (CHILD)

This form is for patients who are under sixteen years of age.

Please only complete this form if you have been asked to.

Last Updated: 18/10/2024

Your child's contact details

HOME TELEPHONE *

MOBILE TELEPHONE *

EMAIL ADDRESS

PREFERRED CONTACT METHOD *

Letter

SMS

DO YOUR CHILD HAVE ANY INFORMATION OR COMMUNICATION NEEDS? *

Yes No

IF YOU SELECTED YES, HOW CAN WE MEET THEIR NEEDS

CONSENT TO USE MOBILE NUMBER FOR TEXT ALERTS? *

Yes No

WHAT IS YOUR CHILD'S NOMINATED PHARMACY? (NAME AND ADDRESS) *

Details

Child's Date of Birth *

Information about your child

Medical History

We require full access to your records and also permission to share your records with other health care providers under the NHS umbrella to be able to provide you with our services.

DO YOUR CHILD HAVE ANY CURRENT MEDICAL PROBLEMS? *

Yes No

IF YES, PLEASE STATE WHAT IT IS AND THE YEAR(S) WHEN THEY WERE FIRST DIAGNOSED?

IS YOUR CHILD TAKING ANY MEDICATION? *

Yes No

IF YES, PLEASE PROVIDE A COPY THE REPEAT LIST

DO YOUR CHILD HAVE ANY ALLERGIES? *

Yes No

IF YES, PLEASE STATE WHAT THEY ARE ALLERGIC TO BELOW (PLEASE TYPE N/A IF THEY HAVE NO ALLERGIES) *

Family History

HAS ANYONE IN YOUR CHILDS FAMILY BEEN DIAGNOSED WITH ONE OF THE FOLLOWING?

Heart Attack

Stroke

Diabetes

Mental Illness

High Blood Pressure

Asthma

Eczema

Cancer

Epilepsy/Fits

Next of Kin

Child's Next of Kin and their relationship to your child

NAME OF NEXT OF KIN *

RELATIONSHIP TO YOUR CHILD *

THEIR ADDRESS

CONTACT NUMBER *

Carer Information

IS YOUR CHILD A CARER? DO THEY LOOK AFTER SOMEONE WHO RELIES ON THEM FOR SUPPORT? *

Yes No

IF YES, WHO DO THEY CARE FOR?

DOES YOUR CHILD HAVE A CARER? *

Yes No

IF YES, WHAT IS THEIR CARER'S NAME?

CARERS CONTACT NUMBER

CARER'S ADDRESS

Signature

RELATIONSHIP TO CHILD *

SIGNED *

DATED *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

New Patient Health Check Questionnaire (CHILD)

Further Information