Leith Walk Surgery – New Patient Information Sheet (Children)

Surname:Forename(s):

Address:

PostcodeTelephone: / no telephone number

Date of Birth: Sex: Male / Female

  • Has your child been registered at Leith Walk Surgery before? Yes  No 
  • Is your child eligible to receive NHS treatment/services? Yes  No 

If you are unsure whether they are eligible please check with the receptionists. If you claim for NHS treatment/services that you are not entitled to, the NHS Scotland Counter Fraud Team may investigate you.

The Practice may ask for proof of eligibility when you register your child as a patient.

  • If English is not your first language which language do you speak?

Previous GP

  • Has your child been previously been registered with a GP in the UK?

Yes No

If yes please provide details below

Surgery Name:

Address:

Postcode:Telephone:

Previous Health Visitor

  • If your child is under 5 years please provide details of their health visitor

Health Visitor:

Contact Details:

Ethnic Monitoring

Please indicate your child’s ethnic origin. This is not compulsory, but may help with their healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.

This question follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.

Choose ONE section from A to E, and then tick ONE box to indicate your background.

If you do not wish to answer this question please tick this box. 

AWhite

British
Irish
Any other white background please write in below

BMixed

White and Black Caribbean
White and Black African
White and Asian
Any other mixed background please write below

CAsian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background please write below

DBlack or Black British

Caribbean
African
Any other black background please write below

EOther ethnic group

Chinese
Any other please write below

Medical History

  • Does your child have or have they had any of the following? If yes please give approximate date of onset and any additional information regarding your condition

AsthmaYes  NoDate:

DiabetesYes  NoDate:

EpilepsyYes  NoDate:

CancerYes  NoDate:

  • Have they had a major operation, or any operation in the last 2 years?

If yes please provide details including dates.

  • Please provide details of any other illnesses he/she has or has hadin the past. Include dates if known
  • Do you have any concerns about your child’s health and/or development?

If yes please provide details

Current Medication

  • Does your child take any medicines, including those not prescribed by a doctor, regularly? If yes please provide details below.

Name of Drug / Dose / Strength if known / How many times per day
Family History
  • Has anyone in their family had any of the following illnesses? If yes please provide details including their relationship to you and their age when diagnosed if known

Heart Attack(s) Yes  No

AnginaYes  No

Stroke(s)Yes  No

AsthmaYes  No

DiabetesYes  No

High Blood PressureYes  No

CancerYes  No

EpilepsyYes  No

Mental IllnessYes  No

Allergies

  • Is your child allergic to any drugs?Yes  No 

If yes please provide details below

Drug name

When were they prescribed it

What happened please tick all appropriate boxesRash  Sick  Diarrhoea  Breathing difficulties  Other 

Drug name

When were they prescribed it

What happened please tick all appropriate boxesRash  Sick  Diarrhoea  Breathing difficulties  Other 

If they have been allergic to additional drugs please record details on an additional sheet

  • Have they any other allergiesYes  No 

If yes please provide details below

Allergic to

What happened please tick all appropriate boxesRash  Sick  Diarrhoea  Breathing difficulties  Other 

Allergic to

What happened please tick all appropriate boxesRash  Sick  Diarrhoea  Breathing difficulties  Other 

Please continue on additional sheet if necessary

Vaccinations and immunisations

  • Has your child received the following immunisations? If yes please provide dates for all courses given. You may find it helpful to refer to their red child health book.

Diptheria & TetanusYes  No Dates:

HIBYes  No Dates:

Pertussis (whooping Cough)Yes  No Dates:

PolioYes  No Dates:

Meningitis CYes  No Dates:

MMRYes  No Dates:

Pre-school boosterYes  No Dates:

School leavers boosterYes  No Dates:

Patient Declaration

I can confirm that the details provided above are complete, true and accurate.

Parent/Guardian Signature Date:

Practice use only

Registered 

Scanned

Data entry complete