Health Questionnaire – 0 to 5 – Bruntsfield Medical Practice

Personal Details

Title

Name

First

Last

Date of Birth

Gender

Male

Female

Non-binary

Address

House name / Flat No

Street address

Postcode

City

Country

Who else lives in your household?

HOME Phone Number

Do you consent to have messages about your child left on voicemail?

Yes

Email Address

Do you consent to use of your email as a way for us to contact you about your child?

Yes

Owner of address?

MOBILE Phone number

Do you consent to have messages about your child left on voicemail?

Yes

Owner of mobile?

Next of Kin

Medication

Is your child on any regular medication?

Yes

* (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) *

Please state name and dose of all their current medications

Is your child allergic to any medications?

Yes

If yes, please state name of medication and type of reaction they had

Contact with Other Agencies

Under the current Child Health & Wellbeing Guidance, we are obliged to ask the following for all new registrations to the Practice between the ages of 0-16 years.

Does anyone in your household currently have contact with any of the following support services?

A: Social Word Department

Yes

B: Mental Health Services

Yes

C: Drug/Alcohol Support Services

Yes

If yes to any, please give brief details

Immunisations

Please note without immunisation history we are unable to fully register children.

A current photocopy of the immunisation history is the preferred option (e.g. from the red book); we can take a photocopy of this at reception, or you can upload it using the same form as the registration form and proof of id.

If this is not available then please specify the dates for each applicable immunisation below.

1st Diphtheria, Tetanus, Pertussis (Whooping Cough) / Polio / Hib / Hep B

2nd Diphtheria, Tetanus, Pertussis (Whooping Cough) / Polio / Hib / Hep B

3rd Diphtheria, Tetanus, Pertussis (Whooping Cough) / Polio / Hib / Hep B

1st Rotavirus

2nd Rotavirus

1st Meningitis B

2nd Meningitis B

3rd Meningitis B

1st Meningitis C

2nd Meningitis C (if applicable)

3rd Meningitis C (if applicable)

1st Pneumococcal conjugate

2nd Pneumococcal conjugate

3rd Pneumococcal conjugate (if applicable)

Other Pneumococcal (if applicable)

Hib / Meningitis C

1st Measles, Mumps, Rubella (MMR)

Booster Measles, Mumps, Rubella (MMR)

Booster Diphtheria, Tetanus, Pertussis (Whooping Cough) / Polio / Hib

BCG

Details of any other immunisations:

Confirmation

I confirm that I have read and understood this form, and completed it honestly and to the best of my knowledge

Confirm

Your Name

First

Last

Relationship to the child?

reCAPTCHA

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Health Questionnaire – 0 to 5

Personal Details

Medication

* (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) *

Medical History

Has your child had/still have any of the following conditions:

Family History

Has a first degree relative (parent or sibling) of your child suffered from any of the following conditions?

Contact with Other Agencies

Under the current Child Health & Wellbeing Guidance, we are obliged to ask the following for all new registrations to the Practice between the ages of 0-16 years.

Does anyone in your household currently have contact with any of the following support services?

Immunisations

Please note without immunisation history we are unable to fully register children.

A current photocopy of the immunisation history is the preferred option (e.g. from the red book); we can take a photocopy of this at reception, or you can upload it using the same form as the registration form and proof of id.

If this is not available then please specify the dates for each applicable immunisation below.

Ethnicity & Language

Choose ONE section from A to G then choose ONE option which best describes your child's ethnic group or background

Confirmation

Personal Details

Medication

***** (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) *****

Medical History

Has your child had/still have any of the following conditions:

Family History

Has a first degree relative (parent or sibling) of your child suffered from any of the following conditions?

Contact with Other Agencies

Under the current Child Health & Wellbeing Guidance, we are obliged to ask the following for all new registrations to the Practice between the ages of 0-16 years.

Does anyone in your household currently have contact with any of the following support services?

Immunisations

Please note without immunisation history we are unable to fully register children.

A current photocopy of the immunisation history is the preferred option (e.g. from the red book); we can take a photocopy of this at reception, or you can upload it using the same form as the registration form and proof of id.

If this is not available then please specify the dates for each applicable immunisation below.

Ethnicity & Language

Choose ONE section from A to G then choose ONE option which best describes your child's ethnic group or background

Confirmation

* (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) *