Old Bridge Surgery

01503 266960

New Patient Health Questionnaire – Child (Under 16 years old)

The doctors and staff welcome you and your family to the Practice. In order for us to provide you with good quality care, it would be helpful if you could complete the questionnaire below for your child/each of your children (under the age of 16 years old) to provide us with some information to help with their care.

Please note that you will still be required to bring 2 forms of I.D. down to the surgery to complete your registration. (We require photographic I.D. and proof of address i.e. passport and utility bill).

  • Personal Details

  • DD slash MM slash YYYY
  • (By providing my home number I consent for Old Bridge Surgery to use it to contact me).
  • (By providing my mobile number I consent for Old Bridge Surgery to use it to contact me).
  • (By providing my e-mail address I consent for Old Bridge Surgery to use it to contact me).
  • (If you require a translator to attend your consultations then please notify reception)

  • Parent/Guardian Details:

  • Siblings:

  • General Information

  • Medical History

  • (Please bring down to the surgery a repeat slip if possible)

  • Immunisation History

    Please provide the dates these immunisations were administered:
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Family History

Date published: 18th July, 2017
Date last updated: 24th August, 2017