Parent/carer health update questionnaire

Please complete this questionnaire and submit to the children in care health team.

The nurse will use the information provided to inform the review health assessment for the young person in your care which will be due to take place shortly.

Name of young person *

Young person's date of birth *

Ethnicity

Religion

If 'other', which religion?

GP details

Name

Address

GP phone number

Please list any GP/hospital appointments and/or A&E, minor injuries attendances over the past year, reason for visit and any treatment

Please list any immunisations in the past year and the dates they were given (including flu vaccination):

Dentist details

Name

Address

Dentist phone number

Date of last check up and details of any treatment (Statutory requirement is every 6 months)

Orthodontist details

Name

Address

Orthodontist phone number

Date of last check up and details of any treatment

Regular medication: name of medication, frequency and dose

Allergies

Has the young person attended any other health appointments or health specialists over the past year? (e.g. speech therapist, CAMHS, paediatrician, physiotherapy etc.)

Please give dates, describe the reason for appointment, outcome and any follow up

Do you have any concerns about your young person's health or how they look after themselves?

Have you received any support yourself in how to manage your young person's difficulties or behaviour?

If no, do you feel like you would benefit from some help. Please give details.

If yes, from whom?

Parent/carer contact details:

Carer name

Email address

Phone number

Preferred method of contact

Questionnaires for Dorset Council