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Monton Medical Practice NHS GP Surgery in Eccles

New child patient questionnaire

New Child Patient Questionnaire

Personal Details of Child

First Name(s): *

Surname: *

Date of Birth: *

Gender:

Female

Male

Parent’s Email Address: *

Parent’s Mobile Phone:

Home Telephone:

Ethnicity:

Town of birth:

Address:

Previous GP Details (If Applicable)

Surgery Name:

Telephone Number:

Address:

Medication

Do you take any regular medication?

Yes

Please send a repeat prescription slip from your previous GP surgery.

School / Nursery

Name:

Telephone:

Address:

Does the child have learning difficulties or a disability?

Yes

Please give details:

Are you a carer?

Yes

Please state the name:

Legal Guardian Details 1

Name:

Relationship to child:

Mobile Phone:

Address:

Legal Guardian Details 2 (if applicable)

Name:

Relationship to child:

Mobile Phone:

Address:

Health Conditions

Please list any significant health problems, illnesses, admissions to hospital, operations, etc.:

Have you ever declined your child’s immunisations?

Yes

Please give more details:

Summary Care Records

All patients now have a summary care record; which makes your critical data available to other Heath Care Professionals. The critical data is your recorded medication, allergies, and adverse reactions. The Summary care Records can be accessed, with your permission, for example by other health care professional if you need to attend A&E.

Are you happy to opt in to the Summary Care Record?

Yes

Please sign:

If you are human, leave this field blank.

Canal Side
Eccles
Manchester
M30 8AR

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0161 789 0011

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