If so, who: No Please let us know if your child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs, or substance misuse problems. If so, do you think they would like additional support as a young carer? Yes No Is your child known to services such as young carers? Yes No Is your child being looked after by a friend, neighbour in their home? Yes Private Fostering No If yes how long have they been living Is someone looking after your child at home? Yes Please let us know if a family member, friend or neighbour to look after your child. No Carer’s name and address: Relationship to you: Carer’s Tel. number: 5 Your Child’s Medical Background. Please give information any serious illnesses, operations, or injuries your child has had in the past? Condition Year Diagnosed Yes / No Ongoing Is your registered with a dentist? Yes No To find a dentist NHS Choices www.nhs.uk Please provide details of any medication your child takes (including the contraceptive pill): Name: Dosage: Frequency: Please give details of any allergies or sensitivities your child may have to medication/food: Family History
If so, who: Please let us know if your child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs, or substance misuse problems. No If so, do you think they would like additional support as a young carer? Yes No Is your child known to services such as young carers? Yes No Is your child being looked after by a friend, neighbour in their home? Private Fostering If yes how long have they been living Yes No Is someone looking after your child at home? Please let us know if a family member, friend or neighbour to look after your child. Yes No Carer’s name and address: Relationship to you: Carer’s Tel. number: 5 Your Child’s Medical Background. Please give information any serious illnesses, operations, or injuries your child has had in the past? Condition Year Diagnosed Ongoing Yes / No Is your registered with a dentist? To find a dentist NHS Choices www.nhs.uk Yes No Please provide details of any medication your child takes (including the contraceptive pill): Name: Dosage: Frequency: Please give details of any allergies or sensitivities your child may have to medication/food: Family History
New%20Pattient%20Health%20Questionnaire%20U18%20registration%20&%20SCR%20forms.docx