Child Transfer Form December 2011

							                                                                 Hampshire Community Health Care


      CHILD TRANSFER /CHANGE OF ADDRESS FORM

DATE:   …………………………………………..

TO:     Child Health Records Department            FROM:    Health Visiting Team
        Basingstoke and North Hampshire Hospital            Chase Community Hospital
        Aldermaston Road                                    Conde Way
        Basingstoke                                         Bordon
        Hants                                               Hants
        RG24 9NA                                            Tel: 01420 483827
                                                            Fax: 01420 478720
                                                            E-mail: hamp-pct.bordonhvteams@nhs.net


Mother’s First Name ………………………… Mother’s Last Name: ………………………
Mother’s DOB:
Have the notes been handed over to the new HV?  YES/NO
Have the notes been passed via Safeguarding?    YES/NO

(BLOCK CAPITALS PLEASE)
Surname of child/children



Forenames                                NHS Number                  Date of Birth              Sex


                                                                                                M/F


                                                                                                M/F


                                                                                                M/F



Previous Address                                   New Address




Postcode                                           Postcode

                                                   Tel No


Previous GP                                        New GP


Previous GP Practice                               New GP Practice


Previous HV                                        Previous HV


Previous Treatment Centre                          New Treatment Centre
                                                   IMMUNISATION STATUS

                                                                                 Date Given
                       Course
                                                         Child 1                   Child 2                    Child 3
    st
1 Primary, Polio, Hib
    nd
2        Primary, Polio, Hib
    rd
3 Primary, Polio, Hib
    st
1 Meningitis ‘C’
    nd
2        Meningitis ‘C’
    rd
3 Meningitis ‘C’
    st
1 Pneumococcal (PCV)
    nd
2        Pneumococcal (PCV)
Pneumococcal Booster (PCV)
Hib/Men C Booster
MMR
MMR 2
Dip/Tetanus/Polio (pre-school)
Dip/Tetanus/Polio (pre-school) Hib
BCG
    st
1 Hepatitis B
    nd
2        Hepatitis B
    rd
3 Hepatitis B
    th
4 Hepatitis B
Other (please state course and dose)
Other (please state course and dose)
Other (please state course and dose)

                          NEWBORN BLOOD SPOT SCREENING (UNDER 1 YEAR OLDs ONLY)
                       Please state result clearly and provide further information if results not available

Date of Test:
Results                                       County of Test           Child 1             Child 2             Child 3
PKU (Phenylketonuria)
CHT (Congenital Hypothyroidism)
CF (Cystic Fibrosis)
MCADD
SCD (Sickle Cell)

If results not available please fill in the table below

                                                         Child 1                   Child 2                    Child 3
Original result missing                                  Y N                       Y N                        Y N
Original test declined                                   Y N                       Y N                        Y N
Referral made for re-test or first test                  Y N                       Y N                        Y N
Referred to: ……………………


Date of Appt: ………………………..

Please note cystic fibrosis cannot be screened after 56 days of age