Spring House Medical Centre – New Patient Questionnaire



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Spring House Medical Centre – New Patient Questionnaire (CHILD 16 years old and under)

Please fill this questionnaire in CAPITAL letters

Patient Details




Name:

Height (roughly if unknown):

Waist (in cm):

Weight (roughly if unknown):

Address:
Postcode:

Exercise (for 12 years old & over)

Light Moderate Heavy Impossible

Date Of Birth:

Smoking Status (for 12 years old & over)

Mobile No:

Please tick if you do not wish to receive text message reminder

Passive Smoker  Never Smoked Ex-Smoker

Current Smoker - How many: _______per day.



Diet

Gender: Male  Female 

Average Vegetarian Vegan

Ethnic Origin

Medical History

White British White Irish Other White

Black Caribbean Black African

Other Black Black Caribbean & White

Black African & White Other Mixed

Indian Pakistani Bangladeshi Chinese Other Asian Do not wish to state

Other Ethnic Group - Please State below:

____________________

Does the CHILD suffer with:

Asthma Heart Disease Diabetes Cancer Epilepsy 



Known Allergies:

Does ANYONE IN THE FAMILY suffer from:

High Blood Pressure CVA/ Stroke Asthma Heart Disease Diabetes Cancer Epilepsy Depression No Significant Family History  Other  - Please state: ________________________


Parent / Next of Kin

Name:

Contact No:

Relationship:




Have you had the following Immunisation?




Language support

Please add the date of each immunisation.







DTP – Diphtheria, Tetanus, Pertussis

Polio

Hib

Meningitis C

2 months













3 months













4 months


















MMR

Hob Booster

12-18 months







18 months – 4 years old









Pre-school Boosters

DTP

Polio Booster

MMR

Single Meningitis C

3-4 years old















School Boosters

BCG

Tetanus

Polio

Diphtheria booster
















Others – Please state:



What is your First Language:______________

Do you speak English:______________





Do you use any of the following:

Sign Language: Yes No

Hearing aid: Yes No





Childs School details

Name of school:

Address:


Contact number:


















Protection Plan


Foster care information

Do you consider the child to be a disabled person?




Religion

Christian  Buddhist Hindu

Jewish Muslim Sikh

No religion



Is this child subject to a child protection plan?
Yes  No 

Is this child in:

Foster care  Private Foster 

None of the above 





If Yes, Social Worker Details

No

Yes - Please specify below:


_________________________







Name:




Other – please state:


Contact No:













Do not wish to state













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