BURNHAM MEDICAL CENTRE

							            BURNHAM MEDICAL CENTRE - CHILDREN UNDER 5
                  APPLICATION FOR REGISTRATION
Welcome to Burnham Medical Centre. We would be grateful if you, as parent or guardian of
a child under 5, would spend a few minutes completing this questionnaire. The questionnaire
will need to be completed and handed to the receptionist with a medical card or GMS1 form
before registration can be considered.
                              Please write clearly using black ink.
Surname:                           First name:                            Male/Female

Address:


                                                               Post Code……………..…..
Parent’s or Guardian’s Telephone no:      Parent’s or Guardian’s Mobile no

Previous surname (if any)                 Date of Birth:

Mother’s /Guardian’s name if different:   Father’s / Guardian’s name if different:

Previous GP’s name and address (if applicable):
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Does your child have a carer? If so, please give details:
Name………………………………………………….Relationship to child:…………………
Address:…………………………………………………………………………………………
………………………………………………………………………………………………….
Telephone No (landline & mobile, if applicable):………………………………………………

Has your child had any operations? If so, please give details of operation and what was
the operation was for?
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Does your child suffer from any allergies?
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Has your child had any health problems other than minor illness (i.e. coughs and colds)?
…………………………………………………………………………………………………
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Is your child taking any medication at present? Please list the drugs and their doses:
…………………………………………………………………………………………………
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                                    Please continue overleaf
               BURNHAM MEDICAL CENTRE - CHILDREN UNDER 5
                     APPLICATION FOR REGISTRATION


Immunisation Dates (approximate if not known)
:
1st Triple Hib/Men C……………………2nd Triple Hib/Men C………………………………
3rd Triple Hib/Men C……………………1st MMR……………………………………………
Pre-school booster……………………………………………………………………………..
2nd MMR………………………………….Meningitis C……………………………………..
Have you ever refused any childhood immunisations? Yes / No
If yes, what and why?………………………………………………………………………….
…………………………………………………………………………………………………
…………………………………………………………………………………………………


ETHNIC ORIGIN – Please tick appropriate box
This information is used to identify risk factors. Some groups have more care needs and are at risk of specific
diseases. Ethnic group data can help treat patients and support service users by alerting staff to high-risk groups.


ASIAN OR ASIAN BRITISH
[ ] Bangladeshi [ ] Indian [ ] Pakistani
[ ] Any other Asian background (please write in) ……………………………………..
…………………………………………………………………………………………..

BLACK OR BRITISH BLACK
[ ] African [ ] Caribbean [ ] Any other Black background (please write in)
…………………………………………………………………………………………..

CHINESE OR OTHER ETHNIC GROUP
[ ] Chinese [ ] Any other (please write in) …………………………………………..

MIXED
[ ] White and Asian [ ] White and Black African [ ] White and Black Caribbean
[ ] Any other Mixed background (please write in) …………………………………..…
…………………………………………………………………………………………..

WHITE
[ ] British [ ] Irish [ ] Any other White background (please write in) ……………
………………………………………………………………………………………….

Ethnicity Unknown [ ]                                           Ethnic Group not given (patient refused) [ ]