New Patient Safeguarding Questionnaire (for under 18s) - Rowlands Road Surgery

Please complete all sections in full

Contact Details

Name of previous schools (if any) *

Has your child ever been suspended or excluded from school? *

Yes No

Name of Health Visitor/School Nurse (if known)

Has the child ever been the subject of a Child Protection Plan? Please state Yes / No. If yes, when? *

Has your child ever been a “Looked After” child (i.e. in Foster Care or in a Children’s Home)? *

Yes No

What type of house does the child live in? Please enter: Privately owned, Council owned House or flat (If flat which floor?) *

Are there any housing problems? e.g. overcrowding, damp *

Please list all the people (children and adults) that share the house with the child and their relationship to the child *

Full Name *

Enter Mother's name and Father's name *

Address (if different from Child's) please indicate if Mother's/Father's address *

Who has parental responsibility? Please state Mother, Father, or Both. If someone else, then please state name and relationship to Child) *

Date of Birth *

Mother's Telephone Number *

Father's Telephone Number *

Next of Kin (Emergency Contact - if different from above) enter Name, Address, Home, Work and Mobile Telephone Numbers and Relationship *

If your child is under 1 year of age: were they premature? *

Yes No

Is your child home-schooled? Please state Yes / No. If No, which school do they attend *

Signature

Name of Person completing this form *

Date *

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Page last reviewed: 22 September 2022
Page created: 12 October 2022

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