Child Health Questionnaire

Immunisations

Please provide a copy of the child's red book or immunisation history with your registration.

The UK immunisation schedule is as follows.

2 months - diphtheria, tetanus, whooping cough, polio, haemophilus influenzae b, pneumococcal

3 months - diphtheria, tetanus, whooping cough, polio, haemophilus influenzae b, meningitis c

4 months - diphtheria, tetanus, whooping cough, polio, haemophilus influenzae b, pneumococcal

12 months - haemophilus influenzae b, meningitis c

13 months - measles, mumps, rubella, pneumococcal

3-5 years - diphtheria, tetanus, whooping cough, polio, measles, mumps, rubella

Next of kin or emergency contact

Please provide details of your next of kin or a person we should contact in case of any emergency with you.

Your health history

Please list any long term illnesses, accidents, operations, and diagnosed medical problems you have. Please write none if you have nothing to list. *

Please list any allergies or adverse reactions you have to foods, medicines or other things. Please write none if you don't have any. *

Please list any medications you are taking regularly. Please write none if you don't take any. *

Please tell us about your smoking habits. *

If you currently smoke or used to smoke please tell us what and how many per day, and if applicable when you gave up.

What is your height? *

What is your weight? *

Family history

Please tell us about any significant health problems in your close family.

Asthma (tell us which relations have this)

COPD (tell us which relations have this)

Epilepsy (tell us which relations have this)

Heart attack or heart failure (tell us which relations have this)

Stroke (tell us which relations have this)

High blood pressure (tell us which relations have this)

Diabetes (tell us which relations have this)

Depression (tell us which relations have this)

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