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

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) (optional)

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
For example, 15 3 1984

Day

Month

Year

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

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

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