Health Information Form - Children

Your Child's Details

First Name

Middle Name

Last Name

Date of Birth

Gender

Town and country of birth

NHS Number

Address

Home Telephone

Communication Needs

What is your main spoken language?

Do you need an interpreter?

Do you have any communication needs?

Your Child's Medical History

Has your child suffered from Asthma?

Has your child suffered from Diabetes?

Has your child suffered from Depression?

Has your child suffered from Epilepsy?

Any other conditions, operations or hospital admission details

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here

Your Child's Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Asthma

COPD

Epilepsy

Heart Disease

Stroke

Blood Pressure

Diabetes

Kidney Disease

Liver Disease

Depression

Thyroid

Cancer

Other

Allergies

Please record any allergies or sensitivities below

Current Medication

Please check and include as much information about your current medication below. Please give us your previous repeat medication list if possible and a medication review appointment may be needed

Electronic Prescribing

If you would like your child’s prescriptions to go electronically, please provide details of the pharmacy you would like to use:

Sharing Your Health Record

Do you consent to your GP Practice sharing your Child’s health record with other organisations who care for them?

Do you consent to your GP Practice viewing your Child’s health record from other organisations that care for them?

Your Summary Care Record (SCR)

Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

Parent or Guardian Details

Your Name

Relationship

Address

Home Telephone

Work Telephone

Mobile Telephone

Do you consent to being contacted by SMS on this number

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns

Family Registered With Us

If you are registering for the first time at a practice in England to complete your registration please provide your childs Immunisation Information to the practice

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to James Fisher Medical Centre • 4 Tolpuddle Gardens, Muscliffe, Bournemouth, BH9 3LQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.