Spring House Medical Centre – New Patient Questionnaire

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 N^o: 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