NHS My Personal Child Health Record

personal child health recordmy

© Harlow Printing Limited / Institute of Child Health. This form may be downloaded and reproduced for discussion / evaluation only.

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

my personal child health record

my name

my NHS number

my photo

If this book is found,

please return to:

Somewhere HealthcareNHS Trust


Wherever you seethis symbol it isyour opportunity torecord your child’sdevelopment!

These sections areto be filled in byyourself as a parent,or your doctor orhealth visitor.

INDEX

child & family details1 Child’s details2 Birth details5 Family history6 Local information7 Information sources9 Important health problems

screening / routine reviews10 Screening & routine reviews11 How we handle information12 Can your baby see?13 Can your baby hear?15 6-8 week review16 Other health reviews

immunisation20 The routine immunisations20a Hep B infant vaccine programme21 Primary course of vaccines22 MMR23 Additional vaccinations24 Pre-school booster

growth charts & other information25 Your child’s developmental firsts28 Notes

Growth Charts


PERSONAL CHILD HEALTH RECORD

This record is the main record of your child’s health, growth and development and therefore weask you to keep it in a safe place.The record is to be used jointly by you and by the health professionals caring for your child.

Name: ..................................................................................................................

Date of Birth: ........................................................................................................

Bring this book with you whenever you visit:

✱ the child health clinic

✱ your health visitor

✱ your family doctor

✱ a hospital emergency or outpatients department

✱ a therapist (eg speech and language therapist)

✱ the dentist

✱ the school nurse

✱ any other health appointment


child &

family details

child & fam

ily details


CHILD’S DETAILS

✱ Please place a sticker (ifavailable) otherwise write in spaceprovided.

CHILD

& FAM

ILY DETAILS

1

Surname

First names

NHS Number Unit no.

Address __________________________________________ Sex M / F

_________________Post Code _________________D.O.B. _____/____/____

G.P. Code

H.V. Code

Change of Address (including post code)

1)__________________________________________________________________Tel _______________

2)__________________________________________________________________Tel _______________

3)__________________________________________________________________Tel _______________

Named Midwife______________________________________________________Tel _______________

Family Doctor

1) Name ____________________Address ________________________________Tel _______________

2) Name ____________________Address ________________________________Tel _______________

3) Name ____________________Address ________________________________Tel _______________

Health Visitor

1) Name ____________________Address ________________________________Tel _______________

2) Name ____________________Address ________________________________Tel _______________

3) Name ____________________Address ________________________________Tel _______________


LOCAL INFORMATION

Child health clinics

1) Name ______________________________________Time______________Tel ________________________

2) Name ______________________________________Time______________Tel ________________________

3) Name ______________________________________Time______________Tel ________________________

4) Name ______________________________________Time______________Tel ________________________

5) Name ______________________________________Time______________Tel ________________________

Baby/toddler clinics

Name ________________________________________Time______________Tel ________________________

Name ________________________________________Time______________Tel ________________________

Playgroups

________________________________________________________________Tel ________________________

________________________________________________________________Tel ________________________

Nursery schools/classes

________________________________________________________________Tel ________________________

________________________________________________________________Tel ________________________

Other useful contacts

________________________________________________________________Tel ________________________

________________________________________________________________Tel ________________________

________________________________________________________________Tel ________________________

________________________________________________________________Tel ________________________

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CHILD

& FAM

ILY DETAILS

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BIRTH DETAILS

summary of birth and neonatal information - handover from Maternity Record where possible

Preparation for baby to go home

Hospital/Birth Unit/Home ........................................................................................................

Length .............Date ............... Weight............... Date .............. Head Circ.............. Date..........

Admitted to NICU? YES/NO If YES for how long? .................days

Problems in pregnancy, birth or first month of life

1) ___________________________________________________________________________________

_____________________________________________________________________________________

2) ___________________________________________________________________________________

_____________________________________________________________________________________

Label with Name, NHS number, Address, Sex, Gestation, First milk feedBirth Weight, Date of Birth, Type of delivery, GP and HV. breast bottle


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BIRTH DETAILS

Neonatal Examination

Item Guide to Content Coded Outcome (ring one) Comment/Action Taken

Examination of hips Barlow and Ortolani Right S P O T R NTests on both Left S P O T R N

Testes Ring ‘N’ for girls Right S P O T R NLeft S P O T R N

Examination of eyes Includes inspection Right S P O T R Nand red reflex Left S P O T R N

Rest of Physical Including fontanelle,Examination palate, spine, heart,

abdomen, urine system,passage of meconium

Breast feeding at discharge Totally Partially Not at all

Screening blood tests performed: PKU/Hypothyroidism/Sickle cell/CF/Other (delete any not performed)

Date performed................................

Follow-up required YES/NO

Location/Clinic.......................................... Date ............... Reason ..............................................

Date Performed.................... Performed by .......................................Signature ..............................

The recording of blood test screening results is under discussion. Information to follow.

© Harlow Printing Limited / Institute of Child Health

CHILD

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BIRTH DETAILS continued

BCG offered YES/NO BCG given YES/NO If YES date given..............................

Hep B offered YES/NO Hep B given YES/NO If YES use separate page

(Please enter full details on immunisation page)

Vitamin K given: Date ....................... Route ............................ Further doses needed? YES/NO

If YES specify ...........................................................................................................................


FAMILY HISTORY

Parents: Mother’s name ...................................................................Date of birth...................

Father’s name ....................................................................Date of birth...................

Are there any other children in the family?

Siblings name(s) ............................ ............................ ............................ ..........................

Sex .............................. ............................ ............................ ..........................

Date of Birth .............................. ............................ ............................ ..........................

Yes No CommentsDoes anyone in the household smoke? _____________________________________

Is there any family history of:

Childhood deafness _____________________________________

Fits in childhood _____________________________________

Eye problems in childhood _____________________________________

Hip problems in childhood _____________________________________

Reading and spelling difficulties _____________________________________

Asthma/eczema/hayfever/allergies _____________________________________

Tuberculosis (TB) _____________________________________

Heart Conditions _____________________________________

Are there any other particular illnesses or conditions in the mother’s or father’s family that you feel

are important? ___________________________________________________________________________6


INFORMATION SOURCES

Birth to five

Information to follow

NHS direct

NHS Direct is a 24-hour nurse-led helpline providing confidential healthcare advice and information on:

✱ What to do if you're feeling ill;

✱ Health concerns for you and your family;

✱ Local health services;

✱ Self-help and support organisations.

Calls to NHS Direct are charged at local rates.

NHS Direct Online provides a gateway to high quality and authoritative health information on theInternet. It is unique in being the only UK website supported by a 24-hour nurse-led helpline.

www.nhsdirect.nhs.co.uk

CHILD

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Direct0845CALL 24 HOURS ON

4647


Parent Line Plus

Parentline Plus is a national charity offering help andinformation for parents and families via a range of servicesincluding a free 24-hour confidential helpline, workshops,courses, information leaflets and website.

Services

✱ A free confidential, 24-hour helpline 0808 800 22 22

✱ A free text phone for people with a speech or hearing impairment 0800 783 6783

✱ Parenting courses and workshops

✱ Information leaflets

✱ A helpful website www.parentlineplus.org.uk

✱ Referral Telephone Support

✱ Training for professionals

✱ Volunteer opportunities.

Values

Parentline Plus works to recognise and to value the different types of families that exist and to shapeand expand the services available to them. We understand that it is not possible to separate children’sneeds from the needs of their parents and carers and encourages people to see it as a sign ofstrength to seek help. We believe that it is normal for all parents to have difficulties from time to time.

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Contact a Family

Every day over 75 children in the UK are born ordiagnosed with a serious disability. Discovering that achild is ill or has a special need or disability is alwaysvery difficult and parents may feel very isolated.

Contact a Family gives support, information and advice to families across the UK, regardless of themedical condition of the child.

Contact a Family advisers can

✱ put familes in touch with support groups or, where there isn’t a group, try to link families directlyon a one-to-one basis

✱ give medical information on all conditions affecting children, including rare conditions

✱ advise on services like respite and benefits

✱ send a range of helpful factsheets

✱ talk via an interpreter in over 100 languages if a language other than English is preferred

To get in touch with Contact a Family, parents can

✱ phone the National Freephone Helpline, tel 0808 808 3555 (10am-4pm, Monday to Friday). TheService is free and confidential

✱ use Minicom on 020 7608 8702

✱ email [email protected]

✱ write to Contact a Family, 209-211 City Road, London, EC1V 1JN

✱ look at the website www.cafamily.org.uk which contains the directory of rare conditions andsyndromes affecting children, as well as regional contacts

CHILD

& FAM

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IMPORTANT HEALTH PROBLEMS

1_________________________________________________________ Date __________________

2_________________________________________________________ Date __________________

3_________________________________________________________ Date __________________

4_________________________________________________________ Date __________________

Specialist Clinics

Name_____________________________________________________ Unit Number ____________

Name_____________________________________________________ Unit Number ____________

Name_____________________________________________________ Unit Number ____________

Special needs: (social, physical, educational, emotional)

1_________________________________________________________ Date __________________

2_________________________________________________________ Date __________________

3_________________________________________________________ Date __________________

4_________________________________________________________ Date __________________

Serious allergies and reactions to drugs or vaccines

1_________________________________________________________ Date __________________

2_________________________________________________________ Date __________________

3_________________________________________________________ Date __________________

4_________________________________________________________ Date __________________9


screening

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screening & routine review

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SCREENING AND ROUTINE REVIEWS

Your doctor, health visitor, midwife or school nurse will carry out simple routine checks with your child.

Some of these are called screening tests and include:

✱ hearing tests at birth

✱ blood tests for cer tain conditions which could cause health problems (for example phenylketonuria, hypothyroidism and sickle cell disease)

✱ checks of your baby’s hips

✱ checks of your baby’s heart

✱ checks of your baby’s eyes for cataracts

other checks or reviews include:

✱ checks of weight

✱ checks for undescended testicles

✱ eye checks

✱ dental checks

Screening tests and other health checks and reviews are done to pick up problems before they have beennoticed. They can never be fully accurate in all cases. This means that sometimes there is a false alarm,when you will be told that your baby may have a condition. However, further tests may show that in factshe or he does not have the condition.It also means that sometimes a problem may not be picked up even if it is present. So even if your babyhas had a check for a condition and was found to be OK, if you think there may be a problem you shouldstill point it out to your health visitor or GP. Do not assume that because the check was ‘normal’, therecannot be a problem.


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HOW WE HANDLE INFORMATION

We wish to make sure that your child has the opportunity to have his/her immunisations and healthchecks when they are due. We also want to be able to plan and provide any other services your childneeds. Therefore, we enter some of your child’s details from this record on to our computer system.

We treat this information as strictly confidential and only release it to:

✱ Yourself as parent(s)✱ Your child’s health care professionals, who work directly with your family.This information may be used anonymously so that we can plan services for all children.

We will not normally release any information about your child to any other person or organisationwithout seeking your permission first.We are subject to the terms of the Data Protection Act, 1998 in respect of personal data held by us.You have the right under the Act to ask to see details of the information held regarding your child.


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CAN YOUR BABY SEE?

There is no easy way to test a young baby's eyesight accurately, but you can help check that there is noserious problem by watching how your baby uses his/her eyes.Ask your health visitor or doctor at any time if you are worried about your child’s sight.

Yes NoFirst two months

Does your baby open his/her eyes and look at you?

Does he/she keep looking at you when you move your head from side to side?

Do the eyes look normal?

Is there a family history of serious eye disease?

Babies and toddlers

Does your baby ever seem to have a squint (lazy eye)?

Does your baby have any difficulty in seeing small objects (tiny bits of food, crumbs,bits of fluff)?

Does anyone in the family have a squint (lazy eye), or wear glasses (starting in childhood)?

Age two to school entry

Does the child have any squint or any difficulty in seeing (e.g. watching T.V.,recognising you across a room, bumping into things, being unusually clumsy)?

If you are concerned your child may need glasses, get your child’s eyes checked.Your health visitor will advise you where.


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CAN YOUR BABY HEAR?

These 2 lists give pointers about what to look and listen out for as your baby grows to check if he/she canhear. Babies do differ in what they can do at any given age. The ages presented here are approximate only.

Checklist for Reaction to Sounds

Shortly after birth – a baby Is startled by a sudden loud noise such as a hand clap or a door slamming. Blinks or opens eyes widelyto such sounds or stops sucking or starts to cry.

1 month – a babyStarts to notice sudden prolonged sounds like the noise of a vacuum cleaner and may turn towards thenoise. Pauses and listens to the noises when they begin.

4 months – a babyQuietens or smiles to the sound of familiar voice even when unable to see speaker and turns eyes or headtowards voice. Shows excitement at sounds e.g. voices, footsteps etc.

7 months – a babyTurns immediately to familiar voice across the room or to very quiet noises made on each side (if not toooccupied with other things).

9 months – a babyListens attentively to familiar everyday sounds and searches for very quiet sounds made out of sight.

12 months – a babyShows some response to own name. May also respond to expressions like ‘no’ and ‘bye bye’ even whenany accompanying gesture cannot be seen. If at any stage in the baby or child’s development you think he/she may have difficulties hearing, contactyour health visitor or family doctor.

Adapted from: The ‘Can Your Baby Hear You’ form, B. McCormick, 1982, Children’s Hearing Assessment Centre, Nottingham, UK.


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Checklist for Making Sounds

4 months – a babyMakes soft sounds when awake. Gurgles and coos.

6 months – a babyMakes laughter-like sounds. Starts to make sing-song vowel sounds e.g. a-a, muh, goo, der, aroo, adah.

9 months – a babyMakes sounds to communicate in friendliness or annoyance. Babbles (e.g. ‘da da da’, ‘ma ma ma’, ‘baba ba’). Shows pleasure in babbling loudly and tunefully. Starts to imitate other sounds like coughing orsmacking lips.

12 months – a babyBabbles loudly, often in a conversational-type rhythm. May start to use one or two recognisable words.

15 months – a babyMakes lots of speech-like sounds. Uses 2-6 recognisable words meaningfully (e.g. ‘teddy’ when seeing orwanting the teddy bear).

18 months – a babyMakes speech-like sounds with conversational-type rhythm when playing. Uses 6-20 recognisable words.Tries to join in nursery rhymes and songs.

24 months – a childUses 50 or more recognisable words appropriately. Puts 2 or more words together to make simplesentences e.g. more milk. Joins in nursery rhymes and songs. Talks to self during play (may beincomprehensible to others).

30 months – a childUses 200 or more recognisable words. Uses pronouns (e.g. I, me, you). Uses sentences but many willlack adult structure. Talks intelligibly to self during play. Asks questions. Says a few nursery rhymes.

36 months – a childHas a large vocabulary intelligible to everyone.

Adapted from: M. D. Sheridan (Revised by M. Frost and A. Sharma), 1997, Routledge, London, New York.


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NEWBORN HEARING SCREENING PROGRAMME

Content currently being evaluated as part of the Neonatal Hearing Screening Programme.


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Information will be included here on hips: the content is currently being checked by experts.


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Top copy: Community information system 2nd Copy: HV 3rd Copy: stay in PCHR

FIRST VISIT BY HEALTH VISITOR✱ Please place a sticker (if available) otherwise write in space provided.

Date of contact...............................................

Nature of contact/location...............................

.....................................................................

.....................................................................

.....................................................................

By whom ........................................................

Weight ...........................................................

Breast feeding: Totally Partially Not at all Ethnicity of baby ...............................................

Any concerns about your baby’s feeding? ................................................................................................

.............................................................................................................................................................

Any concerns about you baby’s health or behaviour? ...............................................................................

.............................................................................................................................................................

How do YOU feel? ..................................................................................................................................

.............................................................................................................................................................

Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

H.V. Code

Follow-up required YES/NO Location/Clinic .......................................................................Date/Interval .........................

Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................


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Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

H.V. Code

Item Guide to Content Coded Outcome Comment/Action TakenOther Physical Features General examination, S P O T R N

Fontanelle, Palate, SpineEyes Cataract, Eye movements S P O T R NHearing Stills, Startles, Risk factors S P O T R NLocomotion Tone, Head control S P O T R NManipulation S P O T R NSpeech/Lang. Social smile S P O T R NBehaviour Parental concerns, Sleep, S P O T R N

FeedingHips Check for CDH S P O T R NTestes/Genitalia ‘O’ if testes not fully descended S P O T R NHeart Murmur, Cyanosis, Femorals S P O T R N


Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................

6-8 WEEK REVIEW✱ Please place a sticker (if available) otherwise write in space provided.

Date of contact...............................................

Seen by .........................................................

Place seen....................................

Length (if indicated) ...............cm ..............centile

Weight .......................kg......................centile

Head circ. ..................cm.....................centile

Breast feeding: totally / partially / not at all

Third dose Vit K? NO/NOT NEEDED/GIVEN

Any previous medical problems? YES/NO

If YES specify .................................................


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Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

H.V. Code

.....................................................................................................................................................

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Date of contact...............................................


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By whom ........................................................

Weight ...........................................................

Feeding: any breastmilk yes / no


Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................

HEALTH REVIEW✱ Please place a sticker (if available) otherwise write in space provided.


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Date of contact...............................................


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By whom ........................................................

Weight ...........................................................

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Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................


Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

H.V. Code


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Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

H.V. Code

Date of contact...............................................


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By whom ........................................................

Weight ...........................................................

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Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................


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Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

H.V. Code

Date of contact...............................................


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By whom ........................................................

Weight ...........................................................

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Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................


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Reason ...............................................................................................................................................................................

.....................................................................................................................Signature ........................................................

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Date of contact...............................................


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Weight ........................kg......................centile

Height.........................cm.....................centile

Hearing screen ...............................Pass / Fail

By whom ........................................................

Surname

First names

NHS Number Unit no.

Address ______________________________________________________ Sex M / F

______________________Post Code______________________D.O.B. ______/ ____/ ____

G.P. Code

School Nurse Code

School Code

................................................

SCHOOL ENTRY REVIEW IN RECEPTION CLASS✱ Please place a sticker (if available) otherwise write in space provided.


immunisation

imm

unisation


YOUR CHILD SHOULD HAVE THE FOLLOWING IMMUNISATIONS

Age Due Immunisation

2 months 1st Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio3 months 2nd Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio4 months 3rd Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio12 - 18 months Measles, Mumps, Rubella (1st MMR)

2nd MMR - usually at 3-5 years3-5 years Diphtheria, Tetanus, Whooping Cough, Polio booster10-14 years Heaf, BCG14 years Tetanus, Polio and Diphtheria booster

Signposts

Some babies will need Hep B and/or BCG vaccines. If in doubt discuss with midwife/health visitor

Your health visitor or practice nurse will talk to you and give you written information about immunisations.This and other information is available on www.immunisation.org.uk

Do you know if you are immune to German measles (rubella)? If you are not immune you can have theimmunisation to protect you and future babies.

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HEPATITIS B INFANT VACCINATION PROGRAMME please press firmly

Mother’s Full Name ................................................................Unit Number .........................Date of Birth ......................................

Has been found to be a hepatitis B carrier, her baby should be vaccinated

Baby’s Name .....................................................................................................................Date of Birth ......................................

Address.......................................................................................................................................................................................

Hospital of Birth ................................................................................................................Unit Number .......................................

Hepatitis B immunoglobulin given: Yes No Date ...........................................

Babies should receive a four-dose course of a hepatitis B vaccine according to the following schedule:

Dose Age Vaccine Batch No Site Date Signature Venue

1st Dose Within 48 hoursof birth

Details of 2nd and 3rd doses should be notified on subsequent copies. This copy should be returned to the Immunisation Section

please note: this page is not to be

included in every PCHR, it is only to

be used as applicable


IMMUNISATIO

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Details of 3rd dose should be notified on subsequent copy. This copy should be returned to the Immunisation Section







Address.......................................................................................................................................................................................






2nd Dose 1 month


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Details of booster dose should be notified on subsequent copy. This copy should be returned to the Immunisation Section







Address.......................................................................................................................................................................................






2nd Dose 1 month

3rd Dose 2 months


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Details of serology should be notified on subsequent copy. This copy should be returned to the Immunisation Section







Address.......................................................................................................................................................................................






2nd Dose 1 month

3rd Dose 2 months

Booster 12 months


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This copy should be returned to the Immunisation Section







Address.......................................................................................................................................................................................






2nd Dose 1 month

3rd Dose 2 months

Booster 12 months

Serology(HBs Ag) 12 months


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This copy should remain in PCHR







Address.......................................................................................................................................................................................






2nd Dose 1 month

3rd Dose 2 months

Booster 12 months

Serology(HBs Ag) 12 months


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Surname ..........................................................Forenames .................................................Date of Birth......................................

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

Permanent address:............................................................................................................Postcode ...........................................

GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................

Breastfeedingat 1st Imm: Totally

Partially

Not At All

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (1)

Signed..............................................................................................Date ...............................

Antigen Batch No Dose Site Date Signature Venue

1 Dip/Tet/Pert

Hib

Polio

Meningococcal C

PRIMARY COURSE OF VACCINATIONS please press firmly


IMMUNISATIO

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Details of 3rd dose should be notified on subsequent copies. This copy should be returned to the Immunisation Section


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................

Breastfeedingat 1st Imm: Totally at 2nd Imm Totally

Partially Partially

Not At All Not At All


Signed..............................................................................................Date ...............................


1 Dip/Tet/Pert

Hib

Polio

Meningococcal C

2 Dip/Tet/Pert

Hib

Polio

Meningococcal C



IMMUNISATIO

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This copy to be returned to the Immunisation Section


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................

Breastfeedingat 1st Imm: Totally at 2nd Imm Totally at 3rd Imm Totally

Partially Partially Partially

Not At All Not At All Not At All


Signed..............................................................................................Date ...............................


1 Dip/Tet/Pert

Hib

Polio

Meningococcal C

2 Dip/Tet/Pert

Hib

Polio

Meningococcal C

3 Dip/Tet/Pert

Hib

Polio

Meningococcal C



IMMUNISATIO

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This copy to be retained in the PCHR


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................

Breastfeedingat 1st Imm: Totally at 2nd Imm Totally at 3rd Imm Totally

Partially Partially Partially

Not At All Not At All Not At All


Signed..............................................................................................Date ...............................


1 Dip/Tet/Pert

Hib

Polio

Meningococcal C

2 Dip/Tet/Pert

Hib

Polio

Meningococcal C

3 Dip/Tet/Pert

Hib

Polio

Meningococcal C



IMMUNISATIO

N2

2

VACCINATION (MMR – FIRST DOSE) please press firmly


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................

Breastfeeding at all at 1st birthday Yes No

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below

Signed..............................................................................................Date ...............................


Measles/Mumps/Rubella(1)

Details of 2nd MMR should be notified on subsequent copies. This copy should be returned to the Immunisation Section


IMMUNISATIO

N2

2a

VACCINATION (MMR – SECOND DOSE) please press firmly


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................



Signed..............................................................................................Date ...............................






IMMUNISATIO

N2

2b

VACCINATION (MMR) please press firmly


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................



Signed..............................................................................................Date ...............................








NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................


Signed..............................................................................................Date ...............................


1

2

3

ADDITIONAL VACCINATIONS please press firmly

IMMUNISATIO

N2

3


Details of 3rd dose should be notified on subsequent copies. This copy should be returned to the Immunisation Section


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................


Signed..............................................................................................Date ...............................


1

2

3


IMMUNISATIO

N2

3a


This copy to be returned to the Immunisation Section


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................


Signed..............................................................................................Date ...............................


1

2

3


IMMUNISATIO

N2

3b


This copy to be retained in the PCHR


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................


Signed..............................................................................................Date ...............................


1

2

3


IMMUNISATIO

N2

3c


IMMUNISATIO

N2

4

VACCINATION (PRESCHOOL BOOSTER) please press firmly


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................


Signed..............................................................................................Date ...............................


Diphtheria/Tetanus/acellular pertussis booster

Polio booster

Other



IMMUNISATIO

N2

4a

VACCINATION (PRESCHOOL BOOSTER) please press firmly


NHS No. ....................................................................ID No............................................................... Sex M/F ..........................


GP name & address: ....................................................................................................................................................................

HV name & address: ....................................................................................................................................................................



Signed..............................................................................................Date ...............................


Diphtheria/Tetanus/acellular pertussis booster

Polio booster

Other



growth charts &

other information

growth charts &

other information


YOUR CHILD’S DEVELOPMENTAL FIRSTS

Your baby grows and learns faster in the first year that at any other time. These pages help you to remember somefirsts.

FINDING OUT ABOUT MOVING

GROWTH

CHAR

TS & O

THER

INFO

RMATIO

N2

5

lifts head clear of ground rolls over sits with support sits alone moves around or crawls

stands holding on stands alone walks holding on walks alone first outdoor walk

Age ....................... Age ....................... Age ....................... Age ....................... Age .......................


stares at hands grabs and holds drops things on pulls your hair picks up small thingsbig things purpose

finger feeds feeds with a spoon holds pencil & scribbles opens cupboards


26

FINDING OUT ABOUT HANDS


Age ............................... Age ............................... Age ............................... Age...............................

stares at hands grabs and holds drops things on pulls your hair picks up small thingsbig things purpose

finger feeds feeds with a spoon holds pencil & scribbles opens cupboards


26

FINDING OUT ABOUT HANDS


Age ............................... Age ............................... Age ............................... Age...............................

smiles laughs babbles copies noises

says “mama” – to anyone says recognisable word joins two recognisable words speaks in sentences


GROWTH

CHAR

TS & O

THER

INFO

RMATIO

N2

6

Age ............................... Age ............................... Age ............................... Age...............................

FINDING OUT ABOUT WORDS

Age ............................... Age ............................... Age ............................... Age...............................


FINDING OUT ABOUT PEOPLE

stares at your face moves eyes to smiles for special cries when you holds up arms to usually sleepswatch you people leave the room be lifted through the night

Age ................ Age ................ Age ................ Age ................ Age ................ Age ................

Favourite games: .............................................Age .......... .......................................................Age .........

......................................................................Age .......... .......................................................Age .........

......................................................................Age .......... .......................................................Age .........

......................................................................Age .......... .......................................................Age .........

......................................................................Age .......... .......................................................Age .........

Comments:..............................................................................................................................................

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NOTES

28

NOTES

These pages are for you and others who are in contact with your child to record any information about your child’shealth and/or development.

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All entries should be dated and signed


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All entries should be dated and signed Harlow Healthcare 0191 455 4286 3556dtp

Documents

NHS My Personal Child Health Record