Gade Surgery: Gade House, tel 01923 775291, Witton House, tel 01923 283900

NEW PATIENT QUESTIONAIRE CHILDREN 0-16 YRS

Please complete in black ink

Surname Forename
Address




Dob Religion Country of origin

GENERAL INFORMATION

Name and relationship to child of main carer eg. mother  
First language of child and carer  
Name of school for school age chidren  
Birth weight and any problems at birth and shortly afterwards  
Serious illnesses and operations  
Developmental problems  
Regular medications of any kind  
Allergies  

FAMILY HISTORY (any serious illnesses in close relatives)

Mother  
Father  
Brothers  
Sisters  

IMMUNISATION HISTORY

Diptheria/Tetanus/Pertussis/Hib  
Meningitis C  
Polio  
MMR  

Pre-School Booster

Diptheria/Tetanus  
Polio  
MMR2  



Patient Ethic Origin Questionaire

 
This questionaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act
Please indicate your ethnic origin. This is not compulsory, but may help with your healtcare, 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
Choose ONE section from A to E, and tick ONE box to indicate your background
 

Name:

Date or Birth:

 
A WHITE
   British
   Irish
   Any other white background indicate below
    
 
B MIXED
   White and Black Caribbean
   White and Black African
   Any other mixed background indicate below
    
 
C ASIAN or ASIAN BRITISH
   Indian
   Pakistani
   Bangladeshi
   Any other Asian background indicate below
    
 
D BLACK or BLACK BRITISH
   Caribbean
   African
   White and Asian
   Any other black background indicate below
    
 
E CHINESE or other ethnic group
   Chinese
   Any other please write below
    
 
 
 
 
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