Hamstreet Surgery
New Registration Questionnaire (Age Under 5 years)
Excluding New Birth Registrations

PESONAL DETAILS	DATE:	
NAME:	DATE OF BIRTH:	
ADDRESS:	PHONE NO:

MALE  □	FEMALE  □		
OTHER MEMBERS OF THE FAMILY:	
Name	Relationship	Date of Birth	

			
			
ETHNIC ORIGIN:	White British  □	Black British  □	Other White  □	
Afro-Caribbean  □	Other Black    □	Asian              □	Chinese          □	
Mixed/Other  □ please state……………………………….			
PREVIOUS ADDRESS:

	Previous HV:
Previous GP:

IMMUNISATIONS:	
	Date completed		Date completed	
Primary 1st course		MMR		
Primary 2nd course		Pre-school booster		
Primary 3rd course		Other		
Other		Other		

Does your child have any health/behaviour/development problems?
………………………………………………………………………………………………………………………………………………………………………
Are there any major health problems within the family?
………………………………………………………………………………………………………………………………………………………………………
Is there anything else you would like to tell us?
………………………………………………………………………………………………………………………………………………………………………
SUMMARY CARE RECORD: Your basic details (name, address, allergies, list of acute and regular medications) are uploaded to the national NHS database and can be viewed by other health professionals in an emergency. If you wish to opt out please tick here □ and sign the relevant form (ask at reception if you were not given this when you registered). You can view your summary record at any time – just ask.	

All information disclosed in this questionnaire will be held on our computer records to enable us to provide the best possible care.

Date……………………………………………   Signature of Adult .……………………………………………………………………………….