P O R T R E E M E D I C A L C E N T R E

HOW TO REGISTER WITH PORTREE MEDICAL CENTRE

6 years old to 14 years old

Please complete the enclosed forms:

‘Application to Register Permanently with a General Medical Practice’

‘New Patient Questionnaire’

All boxes marked with * must be completed

CHECKLIST

Have you completed and signed the ‘Application to Register Permanently with a General Medical

Practice’ form?

Have you completed the ‘New Patient Questionnaire’?

Have you indicated your consent/withheld consent to sharing contact details and signed in the

appropriate box?

Are you aware that you need to tell us if you change mobile number or contact details?

If you take regular medication, you need to make an appointment with a GP before you can

reorder it.

PORTREE MEDICAL CENTRE

NEW PATIENT QUESTIONNAIRE

CHILDREN 6 YEARS OLD TO 14 YEARS OLD

PAGE 1

Please complete all sections as fully as possible

Has your child ever been seen at Portree Medical Centre before? Yes No

Name …………………..…………………………….......... Date of Birth …....………………........

Birth or Other Surname ……………………………...... Preferred Calling Name ........................................

Miss Ms Master Other:

Next of kin (name, address and telephone number): _____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Relationship to child: ___________________________________

Ethnicity – We hope that you do not mind completing this section. There may be cultural issues in relation to

healthcare that we should be aware of.

Do you give permission for contact details to be shared, when necessary,

with others involved in your child’s care?

Yes No

Signature ……………………………………………………........ Date …………………..…..

I would describe my child’s ethnicity as:

OtherIndian

Pakistani

Bangladeshi

Chinese

Caribbean

African

Black or Black Scottish

Other Asian

Any mixed background

Other ethnic group

White Scottish

White British

White Irish

Other White

Country of Birth:

UK Other EEC Other (Please specify): ……………………...........…….........

PORTREE MEDICAL CENTRE

NEW PATIENT QUESTIONNAIRE

CHILDREN 6 YEARS OLD TO 14 YEARS OLD

PAGE 2

Personal Health History

Heart Condition Yes No Other

Diabetes Other

Asthma

Have they had any infectious disease? Yes No

Please list any below Date

.........................................................................................................

.........................................................................................................

...........................................

...........................................

Please tell us about current conditions, past illnesses, accidents, operations or other hospital

admissions including, if possible, a date or what age your child was.

Illness/condition/accident/operation/admission etc. Date/age

..................................................................................................................

..................................................................................................................

..................................................................................................................

..........................................

..........................................

..........................................

Family History

Do either of your child’s parents have or have had any of the following:

Heart disease Yes No Mum Dad

Diabetes Yes No

Stroke/CVA

Asthma

High blood pressure

Medication

Please list all medication that your child takes. Please include any medication which is bought from the

chemist.

Name and dose Name and dose

.............................................................................

.............................................................................

..............................................................................

..............................................................................

Does your child have any allergies? Yes No

Which, if any? .....................................................…………………………………………………………………………..

Yes No

Yes No

Yes No

Yes No

Yes No

Mum Dad

Mum Dad

Mum Dad

Mum Dad

PORTREE MEDICAL CENTRE

NEW PATIENT QUESTIONNAIRE

CHILDREN 6 YEARS OLD TO 14 YEARS OLD

PAGE 3

Carers and Being Cared For

The practice offers support and assistance to carers and recognises the invaluable role they take in helping those

being cared for, and we would ask assistance in identifying and supporting carers.

A carer is someone, irrespective of age, who provides or supervises a substantial amount of care on a regular

basis of a child, relative, partner or neighbour who is unable to manage on their own due to illness, disability,

frailty, mental distress or impairment.

The term “carer” would not apply if the person is either a paid carer, a volunteer from a voluntary agency, or

anyone providing personal assistance for payment, either in cash or kind.

We would be grateful if you would answer the following questions:

CARER

Does your child care for someone (as described above)? Yes No

Do we have your permission to include your child’s name on our carers register and to

undertake periodic review of your child’s well-being and support that they may need? Yes No

What is your child’s relationship with the person being cared for? ..………………………………………

Is the person registered with this practice? Yes No

Under the Data Protection Act 2018/General Data Protection Regulation (GDPR), we also need the

permission of the person being cared for before recording their name.

Please advise us of the name and address of the person being cared for:

NAME …..........................………………………………………………………………………………………..…..

ADDRESS ……...........................……………………………………………………………………………………..

We would be grateful if when your child undertakes or ceases a carer role that you advise a member of the

primary care team. This will allow us to maintain up-to-date medical records.

We work closely with Skye and Lochalsh Young Carers. Do you give permission for us to pass your child’s details

onto them?

Yes No

PORTREE MEDICAL CENTRE

NEW PATIENT QUESTIONNAIRE

CHILDREN 6 YEARS OLD TO 14 YEARS OLD

PAGE 4

Being Cared For

Carers can play a significant role in the lives of the people they care for and it helps us to look after your child if

we know of others involved in helping your child with their daily living.

A carer is someone, irrespective of age, who provides or supervises a substantial amount of care on a regular

basis to a child, relative, partner or neighbour who is unable to manage on their own due to illness, disability,

frailty, mental distress or impairment.

It doesn’t matter if the carer is a friend, relative, a voluntary or paid person, or organisation; if your child has

someone who helps them with their daily living activities, please answer the questions below:

Does your child have a carer (as described above)? Yes No

Do we have your permission to record in your child’s medical records that they have a

carer? Yes No

What is their relationship with your child’s carer? ….....…………………………………………………

Is the carer registered with this practice? Yes No

Under the Data Protection Act 2018/General Data Protection Regulation (GDPR), we also need the

permission of the carer before recording their name in your child’s medical record.

Please advise us of the name and address of the carer below:

NAME ….......................………………………………………………………………………………………..…..

ADDRESS ….......................………………………………………………………………………………………..

We will not discuss any aspect of your child’s medical treatment or care with their carer unless we have your

permission to do so.

We would be grateful if you would advise a member of the primary care team if your child starts or stops

having a carer.

Thank you for taking the time to fill in this questionnaire.

Portree Medical Centre, Fancy Hill, Portree, IV51 9BZ

Telephone: 01478 612013