New patient questionnaire (child)

Welcome to the Nuffield Practice

New patient questionnaire (child) :
Please help us by completing the following information. This is very important as it may take some weeks for your medical records to arrive.

Patient's Details - Please complete the text boxes and tick where appropriate

Child:

Surname is required
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Forenames is required
Calling name is required
Sex is required field
Date of birth is required
Ethnic origin is required
First language is required

Parent or guardian:

Surname is required
Forenames is required
Title is required
Address is required
Invalid postcode
Email address is not valid

Telephone numbers:

Invalid home telephone number
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Invalid mobile number

Child’s medical history: Has your child had: (if yes, please give dates)

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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY

Invalid Input
Invalid date. Correct format is DD/MM/YYYY

Invalid Input
Invalid date. Correct format is DD/MM/YYYY

Invalid Input
Invalid date. Correct format is DD/MM/YYYY

Vaccinations: please tick if they have been done, by whom and give dates wherever possible.

Invalid Input
Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY

Invalid Input
Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Invalid date. Correct format is DD/MM/YYYY
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Thank you for completing this form.

Further information

Zero Tolerance Statement

Our staff come to work to care for others, and it is important for all members of the public and our staff to be treated with respect.
We aim to treat our patients courteously at all times and expect our patients to treat our staff in a similary way.

We take seriously any threatening, abusive or violent behaviour againist any of our staff or patients. if a patient is violent or abusive, they will be asked to stop. if they persist, we may exercise our rights to take action to have them removed, immediately if necessary from our pratice list.

The practice considers thratening behaviour to be:

Attempted or actual aggressive threatening physical actions made towards any member of staff.
The use of aggressive, threatening or abusive language, (including raising of the voice, swearing and cursing, shouting) which threatens or intimidates staff.
In line with the rest of the NHS, and to ensure this is fully observed we have a Zero Tolerance policy in place, whereby any aggressive or violent behaviour towards our staff will not be tolerated under any circumstances.

Anyone giving verbal abuse to members of the staff will be sent a letter from the Practice stating that this behaviour will not be tolerated and may result in the removal from the Practice patient list. There will be no appeal process.

We hope that you will understand and welcome this policy which is in place for the best interest of our hard working staff as well as our patients.

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