New Patient Under 16yrs Questionnaire

Last Updated: 30/04/2021

Child's Details

Surname *

First Names *

Date of Birth *

Any previous names or surname

Address *

Home Number

Mobile Number *

Email Address *

Parental Responsibility

Name *

Date of Birth *

Address if different to patient

Telephone Number *

Relationship to Child *

Any Additional Name with Parental Responsibility

Date of Birth

Address if different to patient

Telephone number

Relationship to Child

Details of all current residents at child's home address

School and Education

Name of School or Nursery

My child is homeschooled

Yes No

Past Medical History

Please give details of any past medical history that you feel we should immediately know about your child

Is your child a carer for another person? *

Yes No

If yes, please give details of who they care for and what they do for that person.

Do you have any concerns regarding your child's weight/development/wellbeing? We can arrange a review with either a GP or a nurse, if this is something that you would like to discuss further and will be in contact *

Yes No

If yes, please give brief details so we can arrange a follow-up discussion with the most appropriate clinician.

Are any services involved with your family? Either previously or currently ie school nurse, family support worker, social worker? *

Yes No

If yes, please give details

Consent

Summary Care Record is an electronic record that gives the patient faster, safer care. For example, if your child was admitted to hospital, staff there would automatically be able to access information regarding your child's allergies and medicines, so they provide the correct care and treatment. Enhanced Sharing Model - this is to consent to other organisations that are providing care to your child and are also using the same computer system as us to view your child's medical information but ONLY when they have a clinical reason to do so.

Do you consent to share your child's summary care record? *

Yes No

Do you consent to Enhanced Sharing Model for your child? *

Yes No

Immunisations

We are usually automatically notified with your child's immunisation record, if they have previously been registered with the NHS. If you have previously lived overseas, or lived in Scotland, Ireland or Jersey, we will not be notified and you will need to provide copies of any immunisations your child has received, so we can update their medical record and inform child health. For all children under 6 years of age, please email the immunisation pages from their red book to letters.penryn@nhs.net.

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New Patient Under 16yrs Questionnaire

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