Woodbank Surgery

0161 705 1630

New Patient Questionnaire Children

Patient's Details

Title(Required)

Name

DD slash MM slash YYYY

Information About Your Child

Do you need an interpreter?(Required)

What is your child's Ethnic Group

White(Required)
Black(Required)
Asian(Required)
Mixed(Required)
Please list any serious illness/operations/disabilities and the year they took place in the box below.
Has your child ever suffered from: (Please tick as appropriate)
Is your child allergic to any medications and if so, which?(Required)
Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your child's relationship to the individual.
Please give name, address, telephone number and relationship of next of kin.
Vaccinations(Required)
Please tick any vaccinations your child has had
Please list any other vaccinations that your child has had
Please enter parent/guardian name
This field is for validation purposes and should be left unchanged.