CHILD HEALTH QUESTIONNAIRE

Parkshot Medical Health Questionnaire for Newly Registered Child Patients

Personal Details

Parkshot Medical may contact me about all aspects of my child's health and care using electronic messaging

Parkshot Medical may contact me about all aspects of my child's health and care using electronic messaging

Please indicate ethnicity:

Please indicate ethnicity:

Child's Medical History

Please Complete your child's immunisation history (Please check all that apply) *

DTaP / IPV / Hib (Pediacel)

1st Dose

2nd Dose

3rd Dose

4/Booster

Pneumococcal (PCV)

1st Dose

2nd Dose

3rd Dose

Meningitis B

1st Dose

2nd Dose

3rd Dose

Meningitis C

1st Dose

2nd Dose

3rd Dose

Hepatitis B

1st Dose

2nd Dose

3rd Dose

4/Booster

MMR

1st Dose

2nd Dose

Rotavirus

1st Dose

2nd Dose

BCG

Has your child had any of the following illnesses? (Please check all that apply)

Has your child had any hospital admissions for serious illnesses or accidents?

Has your child had any hospital admissions for serious illnesses or accidents?

Due to Child Protection guidelines, children will not be registered without a parent/legal guardian also being registered at the practice.

A birth certificate may be asked for to confirm who has parental responsibility for a child.

Do you consent for another adult (grandparent, au pair) to seek medical advice/treatment for your child?

Do you consent for another adult (grandparent, au pair) to seek medical advice/treatment for your child?

WE REQUIRE AN UP TO DATE IMMUNISATION HISTORY OF CHILDREN UP TO THE AGE OF 5 UPON REGISTRATION

PLEASE BRING YOUR RED BOOK TO THE SURGERY

Send Your Request

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