New Patient Health Questionnaire (Child Age 0-5)
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Dr A. Bhargava Dr A. Wilkinson Southgate Medical Group Dr K. Olivier 137 Brighton Road Dr M. Morgan Crawley Dr L. Hill West Sussex Dr A. Slater RH10 6TE Telephone 01293 223666 NEW PATIENT HEALTH QUESTIONNAIRE (CHILD AGE 0-5) TITLE – Mr / Master / Miss /.................................. SURNAME……………………………………………. FIRST NAME(S)………………………………………………………………………………………………….. DATE OF BIRTH (dd/mm/yyyy)………….............................. MALE / FEMALE TELEPHONE NUMBER (Home)……………………………….. (Mobile)………………………………….. EMAIL ADDRESS……………………………………………………………………………………………….. □ Please tick if you give EXPLICIT CONSENT to be contacted by: EMAIL / LETTER / TELEPHONE / INFORMATION ON NEW SERVICES/PROMOTIONS & EDUCATION EVENTS □ Please tick if you give EXPLICIT CONSENT to be contacted by SMS TEXT MESSAGE – We will text appointment reminders, or if we need you to contact the surgery for any reason (we do not share this information with any other organisation) NEXT OF KIN – Name………………………………………………………………………………………………………………….. Address……………………………………………………………………………………………………………………………………….. Phone no………………………………………………….. Relationship to the patient………………………………… Mother’s full name………………………………………………………… DOB (dd/mm/yyyy)……………………… PLAYGROUP / PRE-SCHOOL / SCHOOL ATTENDED………………………………………………………............... PLEASE NOMINATE ONE OF THE FOLLOWING CHEMISTS FOR WHERE YOU WOULD LIKE YOUR PRESCRIPTIONS TO BE SENT ELECTRONICALLY (Please tick the appropriate box) (Nomination means you CHOOSE a place for your GP practice to electronically send your prescription. Please see our website or ask at reception for further information.) □ Boots County Mall □ Asda □ Kamsons Central (Town Centre) □ Kamsons Broadfield □ Lloyds Tilgate □ Sainsbury’s □ Kamsons Southgate (Next door to SMG) □ Kamsons Furnace Green □Any other chemist ___________________________________ Information and Communication Needs Do you have any special communication needs? Yes / No If yes: □ Sign Language □ Large Print □ Other If other please provide details: …………………………………………………………………………………………………………………………………. If your preferred method of communication is anything other than standard please give as much detail as possible in order for us to provide the support you require in sending you information (YA842 – Receptionists, Please read code when registering and add on details/ add on a reminder) Do you consent to sharing this information with other providers of NHS and social care if needed:- Yes / No (Y001d) CURRENT MEDICATION (Does the child take any medication that is obtained on prescription from their Doctor?) …………………………………………………..…………………………………………………………………………………………………………………………... PLEASE STATE ANY MEDICAL HISTORY I.E. ILLNESSES, OPERATIONS WITH DATES IF POSSIBLE THAT YOU FEEL THE PRACTICE SHOULD BE AWARE OF: ………………………………………………………………………………………………………………………………………………………………………………… DOES THE CHILD HAVE ANY ALLERGIES TO ANY MEDICATION OR OTHER? ……………………………………………………………. DOES A FAMILY MEMBER SUFFER FROM ANY OF THE FOLLOWING? □ Asthma Specify family member(s)………………………………………. □ Diabetes Specify family member(s)…………………. ………………….. □ Heart Disease (Under 60 years old) Specify family member(s)………………………………………. □ Heart disease (Over 60 years old) Specify family member(s)………………………………………. □ Stroke Specify family member(s)………………………………………. IF ANY IMMEDIATE FAMILY MEMBER HAS DIED, PLEASE SPECIFY, AGE AND CAUSE OF DEATH ……………………………………………………………………………………………………………………………………………………………………………….. Due to government policy, we are obliged to ask you the following: PLEASE STATE YOUR FIRST SPOKEN LANGUAGE………………………………….. English language spoken? YES / NO WHAT IS YOUR ETHNIC GROUP? (Please only choose ONE and tick the appropriate box) WHITE BLACK OR BLACK BRITISH EASTERN ASIAN □British □Caribbean □Chinese □European □African □Vietnamese MIXED ASIAN OR ASIAN BRITISH MIDDLE EASTERN □White & Black Caribbean □Indian □Arabic □White & Black African □Pakistani □Iranian □White & Asian □Bangladeshi □Turkish □ ANY OTHER GROUP NOT STATED ABOVE………..………………………………… □ I DO NOT WISH TO STATE MY ETHNIC GROUP Information Sharing (eDSM) SHARING OF YOUR MEDICAL RECORDS BETWEEN HEALTH PROFESSIONALS In order to provide the best and safest health care it is possible to allow clinicians caring for you to view medical information recorded by other healthcare services. For example it may be useful for your GP to be able to read information recorded by a district nurse to monitor your care and make a more informed decision when planning how best to treat you. Can I refuse to share? Yes, you have the right to choose which services can share information or view shared information and you can change your mind at any time. PLEASE TICK TO “AGREE” TO SHARE INFORMATION OUT (SMG information with other healthcare professionals) □ PLEASE TICK TO “AGREE” TO SHARE INFORMATION IN (Other healthcare professionals information with SMG) □ If I agree to share, who can view my information? Only health professionals who are currently involved in your health care and you have given consent to view can see information in the shared record. PLEASE TICK TO “REFUSE” TO SHARE INFORMATION OUT (SMG information with other healthcare professionals) □ PLEASE TICK TO “REFUSE” TO SHARE INFORMATION IN (Other healthcare professionals information with SMG) □ Can I hide specific entries on my record while sharing the rest of my information? Yes. If there is some information you do not wish to be shared, ask your health professional not to share that information. (SCR) SUMMARY CARE RECORD – your emergency care summary Your Summary Care Record will be available to authorized healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health. As a patient you have a choice, please tick one of the following:- □ Yes I would like a summary care record – Consent for medication, allergies and adverse reactions only □ Yes I would like a summary care record – Consent for medication, allergies and adverse reactions and additional information □ No, I do not want a Summary Care Record – please ask at reception for an opt-out form, complete the form and hand it back to a receptionist Please ask at reception for more information regarding Record Sharing or Summary Care Records. Your childhood Immunisations and Vaccinations history (please give dates where possible) Immunisation Age it is usually Was it given? Date Location given Y/N 1st Diphtheria, tetanus, 2 months old GP/Elsewhere/Out of Country pertussis, polio and HIB 1st Pneumococcal 2 months old GP/Elsewhere/Out of Country 1st Meningitis C 3 months old GP/Elsewhere/Out of Country 2nd Diphtheria, tetanus, 3 months old GP/Elsewhere/Out of Country pertussis, polio and HIB 2nd Pneumococcal 4 months old GP/Elsewhere/Out of Country 2nd Meningitis C 4 months old GP/Elsewhere/Out of Country 3rd Diphtheria, tetanus, 4 months old GP/Elsewhere/Out of Country pertussis, polio and HIB HIB/Meningitis C booster 1 year old GP/Elsewhere/Out of Country 1st MMR 13 months old GP/Elsewhere/Out of Country 3rd Pneumococcal 13 months old GP/Elsewhere/Out of Country 3 years 4 months – 2nd MMR GP/Elsewhere/Out of Country 5 years old Preschool Dip, Tetanus, 3 years 4 months – Pertussis and Polio GP/Elsewhere/Out of Country 5 years old booster School Leavers Dip, 13 – 18 years old GP/Elsewhere/Out of Country Tetanus and Polio Booster 12 – 13 years old 1st HPV vaccine GP/Elsewhere/Out of Country for female patients 1 month after the 2nd HPV vaccine GP/Elsewhere/Out of Country first vaccine 6 months after the 3rd HPV vaccine GP/Elsewhere/Out of Country first vaccine Health Visitor Transfer In Information Sheet Please tick which surgery the patient has registered at Coachmans Woodlands Furnace Green Southgate Other (please x state) Name and address of previous G.P. Surgery Child’s Name D.O.B and NHS no. Child’s Name D.O.B and NHS no. Child’s Name D.O.B and NHS no. Parent/Guardian Current Address Previous Address Landline Mobile Previous Country if English Spoken? Y/N new to this country Any Additional Information Health Visitor Use Only HV Allocation CHB Letter Sent & reassign to T/I caseload Task to allocated Internal T/I Electronic referral request/received HV Please Complete and return to Crawley South HCP Team, Broadfield Children and Family Centre, Creasys Drive, Broadfield, Crawley, West Sussex, RH11 9HJ .