Additional Registration Form/New Patient Questionnaire for under 18s Additional Registration Form /New Patient Questionnaire for under 18s NameFirst and last nameDate of Birth DD slash MM slash YYYY Mother's NameTelephone Number OptionalAddress Details (if different to Child's) OptionalFathers NameTelephone Number OptionalAddress Details (if different to Child's) OptionalWho has parental responsibility? Mother Father Both Other (please state name and relationship to child) Other (please state name and relationship to child) OptionalNext of KinEmergency Contact – if different from aboveName OptionalAddress OptionalTelephone Home Optional Work Optional Mobile Optional Phone Number OptionalOther InformationIf your child is under 1 year of age: were they premature? Yes Optional No Optional If your child home-schooled? Yes Optional No Optional Which School do they attend? OptionalName previous schools Optionalif anyHas your child ever been suspended (fixed-term exclusion) Or permanently excluded from school? Yes Optional No Optional Name of Health Visitor/School Nurse/Family support worker OptionalIs your child currently, or ever been, the subject of a Child Protection Plan or a Child in Need Plan Yes Optional No Optional If yes, when? Optional DD slash MM slash YYYY Why were they on a plan? OptionalIs your child currently, or ever been, a “Looked After” child of “Child in Care” (i.e. in Foster Care or in a Children’s Home)? Yes Optional No Optional If your child adopted? Yes Optional No Optional Do they know? Yes Optional No Optional Are you currently going through an adoption process? Yes Optional No Optional HousingAre you homeless? This includes sofa surfing, living in temporary accommodation, hostel, hotel room Yes Optional No Optional Do you have a Housing Officer? Yes Optional No Optional Please give details OptionalWhat type of accommodation does the child live in? Privately owned Optional Council owned Optional House Optional Bungalow Optional Hostel Optional Hotel room Optional Flat Optional Which Floor? Optional(ground, first floor etc)Are there any housing problems? Overcrowding Optional Damp Optional Mould Optional Please list all the people (children & adults) that share the house with the child and their relationship to themNAME OF PERSONADULT or CHILD (Please give age if under 18)NAME OF PERSON ADULT or CHILD (Please give age if under 18) RELATIONSHIP TO CHILD ARE THEY REGISTERED AT THIS PRACTICE?ARE THEY REGISTERED AT THIS PRACTICE? Add Remove
