SHERE SURGERY & DISPENSARY
Dr Charlotte Knight 						Salaried Doctor:
Dr Emma Watts 							Dr Jennifer Lane
Dr Douglas Wardrop						Dr Amy Bissell
Dr Marcus McEwen
Dr Helen Barnes                                                                                                

NEW PATIENT Under 16 Questionnaire:

Please complete this questionnaire, as it will help us to help you until your records arrive from your previous doctor. Please bring your Childs RED BOOK when you register your child.

Preferred Title:

Surname:

Forenames:

Date of birth:

Age:

Town of birth:

Country of birth:

Nationality:

Mother’s Name:

Father’s Name:

Gender:   Male / Female

 Height:

 Weight:

Current Address:                                                             Previous Address:

Post code:

Home telephone number:
Mobile telephone number:
Email address:

Next of kin …………………………………………… Tel. No. ……………………………..

Relationship………………………………………….

Is your child a carer for someone? Yes [  ]   No [  ]
If yes who do they care for?…………………………………

Relationship……………………………………………………………………………………

Does your child have any allergies?     Yes [  ]   No [  ]

If yes, please list:                       Drugs: ………………………………………….
                                                              ………………………………………….
                                                 
                                                  Others: ………………………………………….
                                                              ………………………………………….

Is your child on a special diet or have any additional nutritional needs?  Yes [  ]   No [  ]
If yes please specify ……………………………………………………………..

Please turn over

Is your child home-schooled? Yes [  ]    No [  ]

Has your child ever been allocated a social worker? Yes [  ]   No [  ] 
If yes, when? ..............................................

Has your child ever been the subject of a Child Protection Plan? Yes [  ]   No [  ] 
If yes, when? ...............................................

Has your child ever been in Foster Care or a Care Home?  	Yes [  ]   No [  ]

Have you, your child or a close blood relative under the age of 60 suffered from any of the following? If yes please state which relative:

Heart Attack: Yes / No …………….... .  Cancer:                Yes / No ………………
Diabetes:       Yes / No …………….....   High BP:              Yes / No ………………
Asthma:         Yes / No ………………..  Tuberculosis:       Yes / No ………………
Stroke:           Yes / No ……………… .  Thyroid problem:  Yes / No………………

Please list any current medication or attach repeat slip:

Drug	Strength	Dose	

			

If your child has regular prescriptions please make a New Patient Appointment for a review with a GP, to enable us to organise repeat medication.

Please detail and date any conditions, operations or serious illnesses your child has had:

Does your child have any communication/ information needs relating to a disability, impairment or sensory loss and, if so, what are they?

Immunisations:  If you do not have your Childs Red Book please bring dates of all immunisations with you when registering your child.

Has your child had their MMR Vaccinations 	Yes [  ]   No [  ]

Is your child up to date with their Immunisations as per the Childrens Immunisation Table within the Practice Leaflet?  	Yes [  ]   No [  ] 
(If the answer is No to the above, you will be invited to come in for a discussion with one of the Clinicians.)  

As a practice we fully support the Childrens Immunisation Programme and would encourage patient uptake for the protection of all our patients here at Shere Surgery.

Would you like a Summary Care Record for your Child?        Yes  [  ]   No [  ]
In event of emergency, it allows other health care providers access to any pre-existing conditions and medication