BARTON HOUSE HEALTH CENTRE

Child Registration

Name:

Date of Birth:

NHS:

Address:

Ethnicity:

Name of Parent/Guardian1:

Date of Birth of Parent/Guardian:---------------------------------------------------------------------------------------Name of Parent/Guardian 2:

Date of Birth of Parent/Guardian:

Is the child allergic to any medication? If so which?

Please note for children under 5 who have had a previous GP we will need to copy the relevant immunisation entries in the child’s Red Book or if coming from aboard the equivalent Immunisations Book or Paperwork.

Patient Profiling FormName DoB

For Office Use only. Date entered on EMIS:Initials:

P a g e | 1 / 4

Please answer these questions. The information will help us plan services for our patients. Giving us this information is voluntary.

What do you consider to be your ethnic origin?White British ArabWhite Irish KosovoTraveller AlbanianGreek BosnianTurkish CroatianKurdish SerbianEstonian/Latvian/Lithuanian Other YugoslavOther White Jewish

British Asian Mixed AsianBengali/British Bengali Pakistani/British PakistaniIndian British Indian Sri LankanTamil SinhaleseChinese VietnameseJapanese FilipinoOther Asian

Black African Mixed BlackBlack Caribbean Mixed White/Black CaribbeanSomali Mixed White/Black AfricanBlack British Mixed White AsianEast African Asian Middle EasternCaribbean Asian Other BlackAny other mixed Other non mixed

I Do not wish to state my ethnicity

In which language would you most prefer us to provide a service to you?English AmharicBengali Sylheti CzechBengali Standard FarsiHindi FrenchUrdu PolishGuajarati PortugueseCantonese RussianVietnamese SpanishSomali British Sign LanguagePunjabi Spoken WordTurkish ArabicAlbanian Other: please specifyIf the service is provided in English, do you need an interpreter/advocate?Yes I do No I do not

Name DoB

For Office Use only. Date entered on EMIS:Initials:

P a g e | 2 / 4

Accessible Information Standard

The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss receive information they can access and understand. For example in large print, braille or via email

Please fill in the questionnaire below, your responses will be added to your medical record for information.

Do you have any communication needs? Yes I do No I do not

If yes please give details …………………………………………...

Do you have any special communication requirements?Yes I do No I do not

If Yes please give details …………………………………………

Do you need a format other than standard print?Yes I do No I do not

If you have a visual impairment do you require:Brail: Yes No Large Print: Yes No

How do you prefer to be contacted? ………………………………

How would you like us to communicate with you? ………………..………………………………………………………………………

Can you explain what support would be helpful when accessing the surgery? …………………………………………………………….………………………………………………………………………

What is the best way to send you information? ……………………

For Office Use only. Date entered on EMIS:Initials:

P a g e | 3 / 4

For Office Use only. Date entered on EMIS:Initials:

P a g e | 4 / 4