New Patient Questionnaire – Child Please provide detailed information about yourself to enable us to provide the best care for you. All information will be kept strictly confidential. This form is for chidren aged 0-15y. About your child Title* MrMiss NHS Number If Known Name* First NameLast Name Date of Birth* /Day /MonthYearDate Gender* MaleFemaleOther Place of Birth* Town & Country If not born in the UK please state date of arrival /Day /MonthYearDate Address* Street Address Street Address Line 2 CityCounty Postcode Home Tel* Mobile Tel* Email* example@example.com Previous GP* Address while at previous GP* Street Address Street Address Line 2 CityCounty Postcode School/Nursery* Current Year Group* Religion* Relationship* Nominated Pharmacy Mothers Name* First NameLast Name Date of birth* /Day /MonthYearDate Contact Number* Email Address* example@example.com Registered at this surgery?* YesNo Fathers Name* First NameLast Name Date of birth* /Day /MonthYearDate Contact Number* Email Address* example@example.com Registered at this surgery?* YesNo Other Guardian Contact Number To which ethnic group would you say your child belongs?* Has your child ever had DiabetesHeart DiseaseHigh CholesterolCancerHigh Blood PressureStrokeEpilepsyAsthmaTBMental Illness Childs Height* Childs Weight* Is your child allergic to any drugs?* YesNo Please specify About Your Family Health Has anyone in your immediate family(i.e parents. siblings or grandparents) suffered from any of the following illness? Family Member Age of onset Comments Diabetes High Blood Pressure Asthma Heart Disease Stroke High Cholesterol Mental Illness Cancer - Specify type in comments Signature Name* First NameLast Name Signature* Clear Date* /Day /MonthYearDate SaveSubmit Should be Empty: