Present Address: Previous Address - 306 Medical …

1 For Office Use Only: COMP No. _ _ _ _ _ NP Check: HEALTH DATA FORM: (under 5 years old) Bills/Bank statement NHS Card Passport 306 Medical Centre Other: Staff Initial: Date: 306 Lordship Lane London SE22 8LY Tel: 020 8693 4704. If you are on a tourist visa you may not be entitled to NHS treatment By completing this form with your personal details, you are granting permission to the practice to contact you using the details provided unless you tick this box. [Please tick box where appropriate]. DATE: Title: Male Female Surname: Forename: Date of Birth: Ethnic Group: Present Address : Previous Address : Post Code Post Code Telephone: Mobile: Email: Parent/s Full Name : Relationship: CHILD IMMUNISATIONS Are the following vaccinations up to date?

2 At Birth Tuberculosis NO YES If YES date (Approx.): 2mths 1st Diphtheria/Tetanus/Whooping Cough (Triple) Polio, Hib & Hep B (from 1 Aug 2017) NO YES If YES date: 1st Pneumococcal NO YES If YES date: 1st Rotavirus NO YES If YES date: 1st Meningococcal B (Men B) - introduced 1 Sept 2015. NO YES If YES date: 3mths 2nd Diphtheria/Tetanus/Whooping Cough (Triple) Polio, Hib & Hep B (from 1 Aug 2017) NO YES If YES date: 1st Meningi%s (Men C) withdrawn from 1 July 2016 NO YES If YES date: 2nd Rotavirus NO YES If YES date: 4mths 3rd Diphtheria/Tetanus/Whooping Cough (Triple) Polio, Hib & Hep B (from 1 Aug 2017) NO YES If YES date: 2nd Pneumococcal NO YES If YES date: 2nd Meningococcal B (Men B)- introduced 1 Sept 2015 NO YES If YES date.

3 12-13mths Haemophilus in uenzae type b (HIB) & Meningi%s (Hib/MenC) NO YES If YES date: 3rd Pneumococcal NO YES If YES date: 1st Measles/Mumps/Rubella (MMR) NO YES If YES date: 3rd Meningococcal B (Men B)- introduced 1 Sept 2015. NO YES If YES date: 15mths 2nd Measles/Mumps/Rubella (MMR 2nd Dose) NO YES If YES date (Approx.): yrs Diphtheria, tetanus, pertussis and polio (dTaP/IPV or DTaP/IPV) - PSB NO YES If YES date (Approx.): PERSONAL Medical HISTORY If you suffer from any illnesses/conditions please enter below with the year in which they occurred.

4 (Do not include influenza, sore throats, unless they keep recurring). Year Condition Year Condition Year Condition Year Condition DRUGS & MEDICINES Are you taking any drugs/medicines/or tablets? Yes No If YES - Please state below the name of the medication and how often you take it Name of medicine Dosage (frequency). Do you have a drug allergy? Yes No If YES - please state: NEXT OF KIN Name: Relationship: Address : Telephone: Check up: It is our practice policy to offer all new patients a check up with the practice. Please make an appointment at reception to have this done within 28 days of registering.

5 Updated Nov17.