Additional Registration Form/New Patient Questionnaire for under 18s
Name
*
First Name
Last Name
Date
*
/
Day
/
Month
Year
Date
Mother's Name
First Name
Last Name
Telephone Number
Address Details (if different from Childs)
Line 1
Line 2
City
County
Post Code
Father's Name
First Name
Last Name
Telephone Number
Address Details (if different from Childs)
Line 1
Line 2
City
County
Post Code
Who has parental responsibility?
Mother
Father
Other
Next of Kin (Emergency Contact - if different from above)
Name
First Name
Last Name
Telephone (Work)
Telephone (Mobile)
Other Information
If your child is under 1 year of age: were they born premature?
Yes
No
Is your child home-schooled?
*
Yes
No
Which school does your child attend?
Name/s of previous schools (if any):
Has your child ever been suspended (fixed-term exclusion) or permanently excluded from school?
*
Yes
No
Name of Health Visitor/School Nurse/Family Support Worker (if any):
First Name
Last Name
Is your child currently, or ever been, the subject of a Child Protection Plan or a Child in Need Plan?
*
Yes
No
Could you provide the date and reason as to why your child was on a plan?
Is your child currently, or ever been a “Looked After” child of “Child in Care” (i.e. in Foster Care or in a Children’s Home)?
*
Yes
No
Is your child adopted?
*
Yes
No
Are they aware they're adopted?
Yes
No
Are you currently going through an adoption process?
*
Yes
No
Housing
Are you homeless? (This includes sofa surfing, living in temporary accommodation, hostel, hotelroom)
*
Yes
No
Do you have a Housing Officer?
Yes
No
Please give name and contact information for your housing officer:
What type of accommodation does the child live in? (Privately owned, Council owned, House, Bungalow, Hostel, Hotel room, Flat (please provide a floor number)
*
Are there any housing problems? (e.g. overcrowding, damp, mould)
Please list all the people (children & adults) that share the house with the child and their relationship to them
Rows
Name of Person
Adult or Child? (please give age if under 18)
Relationship to child
Are they registered at our practice? (YES/NO)
Person 1
Person 2
Person 3
Person 4
Person 5
Submit
Should be Empty: