New Patient Questionnaire PGP (Child)

Child Patient Questionnaire

Last Updated: 05/03/2021

Which Surgery are you registering at?


Personal Details














Home Address







Contact Details





Patient Contacts




Please help us trace your medical records by providing the following:




If you are from abroad




Carers Group





Your medical history (NOT family history)









Health Information



Current Medication


Practice Services / Groups


Other Information / Patient confirmation







NHS Doner Registration


Supplementary Questions


Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. DO NOT complete this section if you have and EHIC issued by the UK.