Nhs My Personal Child Health Record

my

personal child health record

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

my personal child health record my name my NHS number

my photo

If this book is found, please return to:

Somewhere Healthcare NHS Trust

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INDEX child & family details 1 2 5 6 7 9

Child’s details Birth details Family history Local information Information sources Important health problems

screening / routine reviews 10 11 12 13 15 16

Screening & routine reviews How we handle information Can your baby see? Can your baby hear? 6-8 week review Other health reviews

Wherever you see this symbol it is your opportunity to record your child’s development! These sections are to be filled in by yourself as a parent, or your doctor or health visitor.

immunisation 20 20a 21 22 23 24

The routine immunisations Hep B infant vaccine programme Primary course of vaccines MMR Additional vaccinations Pre-school booster

growth charts & other information 25 28

Your child’s developmental firsts Notes Growth Charts

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

PERSONAL CHILD HEALTH RECORD This record is the main record of your child’s health, growth and development and therefore we ask 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

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

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child & family details

child & family details

Surname First names

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

NHS Number

Unit no.

Address __________________________________________

Sex M / F

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

Code

H.V.

Code

CHILD & FAMILY DETAILS

CHILD’S DETAILS

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 _______________

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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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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

CHILD & FAMILY DETAILS

BIRTH DETAILS

If YES for how long? .................days

Label with Name, NHS number, Address, Sex, Gestation, Birth Weight, Date of Birth, Type of delivery, GP and HV.

First milk feed breast bottle

Problems in pregnancy, birth or first month of life 1) ___________________________________________________________________________________ _____________________________________________________________________________________ 2) ___________________________________________________________________________________ _____________________________________________________________________________________

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BIRTH DETAILS Neonatal Examination Item

Guide to Content

Coded Outcome

(ring one)

Examination of hips Barlow and Ortolani Tests on both

Right S P O T R N Left S P O T R N

Testes

Right S P O T R N Left S P O T R N

Ring ‘N’ for girls

Examination of eyes Includes inspection and red reflex Rest of Physical Examination

Comment/Action Taken

Right S P O T R N Left S P O T R N

Including fontanelle, 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.

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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

CHILD & FAMILY DETAILS

BIRTH DETAILS continued

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

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© Harlow Printing Limited / Institute of Child Health

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

Does anyone in the household smoke?

No

Comments _____________________________________

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

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are important? ___________________________________________________________________________ Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

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; CALL 24 HOURS ON ✱ Local health services; ✱ Self-help and support organisations. Calls to NHS Direct are charged at local rates.

CHILD & FAMILY DETAILS

INFORMATION SOURCES

0845 Direct 4647

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

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Parent Line Plus Parentline Plus is a national charity offering help and information for parents and families via a range of services including 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 shape and expand the services available to them. We understand that it is not possible to separate children’s needs from the needs of their parents and carers and encourages people to see it as a sign of strength to seek help. We believe that it is normal for all parents to have difficulties from time to time.

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

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

CHILD & FAMILY DETAILS

Contact a Family

Contact a Family advisers can ✱ put familes in touch with support groups or, where there isn’t a group, try to link families directly on 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). The Service 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 and syndromes affecting children, as well as regional contacts

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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

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1_________________________________________________________

Date __________________

2_________________________________________________________

Date __________________

3_________________________________________________________

Date __________________

4_________________________________________________________

Date __________________

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

screening & routine reviews

screening & 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

SCREENING & ROUTINE REVIEWS

SCREENING AND ROUTINE REVIEWS

✱ checks of your baby’s eyes for cataracts other checks or reviews include: ✱ checks of weight ✱ checks for undescended testicles ✱ eye checks ✱ dental checks

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Screening tests and other health checks and reviews are done to pick up problems before they have been noticed. 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 fact she 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 baby has had a check for a condition and was found to be OK, if you think there may be a problem you should still point it out to your health visitor or GP. Do not assume that because the check was ‘normal’, there cannot be a problem.

HOW WE HANDLE INFORMATION We wish to make sure that your child has the opportunity to have his/her immunisations and health checks when they are due. We also want to be able to plan and provide any other services your child needs. 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 organisation without 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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There is no easy way to test a young baby's eyesight accurately, but you can help check that there is no serious 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

First 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?

No

SCREENING & ROUTINE REVIEWS

CAN YOUR BABY SEE?

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 can hear. 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 widely to such sounds or stops sucking or starts to cry. 1 month – a baby Starts to notice sudden prolonged sounds like the noise of a vacuum cleaner and may turn towards the noise. Pauses and listens to the noises when they begin. 4 months – a baby Quietens or smiles to the sound of familiar voice even when unable to see speaker and turns eyes or head towards voice. Shows excitement at sounds e.g. voices, footsteps etc. 7 months – a baby Turns immediately to familiar voice across the room or to very quiet noises made on each side (if not too occupied with other things). 9 months – a baby Listens attentively to familiar everyday sounds and searches for very quiet sounds made out of sight. 12 months – a baby Shows some response to own name. May also respond to expressions like ‘no’ and ‘bye bye’ even when any accompanying gesture cannot be seen. If at any stage in the baby or child’s development you think he/she may have difficulties hearing, contact your health visitor or family doctor.

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

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4 months – a baby Makes soft sounds when awake. Gurgles and coos. 6 months – a baby Makes laughter-like sounds. Starts to make sing-song vowel sounds e.g. a-a, muh, goo, der, aroo, adah. 9 months – a baby Makes sounds to communicate in friendliness or annoyance. Babbles (e.g. ‘da da da’, ‘ma ma ma’, ‘ba ba ba’). Shows pleasure in babbling loudly and tunefully. Starts to imitate other sounds like coughing or smacking lips. 12 months – a baby Babbles loudly, often in a conversational-type rhythm. May start to use one or two recognisable words.

SCREENING & ROUTINE REVIEWS

Checklist for Making Sounds

15 months – a baby Makes lots of speech-like sounds. Uses 2-6 recognisable words meaningfully (e.g. ‘teddy’ when seeing or wanting the teddy bear). 18 months – a baby Makes 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 child Uses 50 or more recognisable words appropriately. Puts 2 or more words together to make simple sentences e.g. more milk. Joins in nursery rhymes and songs. Talks to self during play (may be incomprehensible to others). 30 months – a child Uses 200 or more recognisable words. Uses pronouns (e.g. I, me, you). Uses sentences but many will lack adult structure. Talks intelligibly to self during play. Asks questions. Says a few nursery rhymes.

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

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36 months – a child Has a large vocabulary intelligible to everyone.

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

SCREENING & ROUTINE REVIEWS

NEWBORN 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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✱ Please place a sticker (if available) otherwise write in space provided. Surname

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

First names

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

NHS Number

Unit no.

..................................................................... M / F

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

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

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

G.P.

Code

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

H.V.

Code

Address ______________________________________________________

Breast feeding:

Totally

Partially

Sex

SCREENING & ROUTINE REVIEWS

FIRST VISIT BY HEALTH VISITOR

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

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? .................................................................................................................................. .............................................................................................................................................................

Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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Top copy: Community information system

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

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

Seen by ......................................................... Surname

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

First names

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

NHS Number

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

Unit no.

Address ______________________________________________________

Sex

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

M / F

Breast feeding: totally / partially / not at all

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

Third dose Vit K? NO/NOT NEEDED/GIVEN G.P.

Code

H.V.

Code

Item Other Physical Features Eyes Hearing Locomotion Manipulation Speech/Lang. Behaviour

Guide to Content General examination, Fontanelle, Palate, Spine Cataract, Eye movements Stills, Startles, Risk factors Tone, Head control

SCREENING & ROUTINE REVIEWS

6-8 WEEK REVIEW

Any previous medical problems? YES/NO If YES specify ................................................. Coded Outcome S P O T R N S S S S S S

P P P P P P

O O O O O O

T T T T T T

R R R R R R

Comment/Action Taken

N N N N N N

Hips Testes/Genitalia Heart

Social smile Parental concerns, Sleep, Feeding Check for CDH S P ‘O’ if testes not fully descended S P Murmur, Cyanosis, Femorals S P

Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

O T O T O T

R N R N R N

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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

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

First names

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

NHS Number

Unit no.

..................................................................... M / F

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

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

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

G.P.

Code

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

H.V.

Code

Address ______________________________________________________

Sex

Feeding: any breastmilk

SCREENING & ROUTINE REVIEWS

HEALTH REVIEW

yes / no

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

Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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

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

First names

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

NHS Number

Unit no.

..................................................................... M / F

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

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

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

G.P.

Code

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

H.V.

Code

Address ______________________________________________________

Sex

SCREENING & ROUTINE REVIEWS

HEALTH REVIEW

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

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

Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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

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

First names

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

NHS Number

Unit no.

..................................................................... M / F

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

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

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

G.P.

Code

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

H.V.

Code

Address ______________________________________________________

Sex

SCREENING & ROUTINE REVIEWS

HEALTH REVIEW

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

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

Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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

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

First names

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

NHS Number

Unit no.

..................................................................... M / F

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

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

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

G.P.

Code

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

H.V.

Code

Address ______________________________________________________

Sex

SCREENING & ROUTINE REVIEWS

HEALTH REVIEW

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

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

Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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

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

First names

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

NHS Number

Unit no.

Address ______________________________________________________

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

M / F .....................................................................

______________________Post Code______________________D.O.B. ______/ ____/ ____ Weight ........................kg......................centile G.P.

Code

School Nurse

Code

School

Code

SCREENING & ROUTINE REVIEWS

SCHOOL ENTRY REVIEW IN RECEPTION CLASS

Height.........................cm.....................centile Hearing screen ...............................Pass / Fail By whom ........................................................

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

..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... Follow-up required YES/NO

Location/Clinic .......................................................................Date/Interval .........................

Reason ............................................................................................................................................................................... .....................................................................................................................Signature ........................................................ 2nd Copy: HV

3rd Copy: stay in PCHR

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immunisation

immunisation

Age Due

Immunisation

2 months 3 months 4 months 12 - 18 months

1st Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio 2nd Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio 3rd Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio Measles, Mumps, Rubella (1st MMR) 2nd MMR - usually at 3-5 years Diphtheria, Tetanus, Whooping Cough, Polio booster Heaf, BCG Tetanus, Polio and Diphtheria booster

3-5 years 10-14 years 14 years

IMMUNISATION

YOUR CHILD SHOULD HAVE THE FOLLOWING IMMUNISATIONS

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 the immunisation to protect you and future babies.

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

IMMUNISATION

HEPATITIS B INFANT VACCINATION PROGRAMME

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

1st Dose

Within 48 hours of birth

Batch No

Site

Date

Signature

Venue

be not to s i e g a o : this p R, it is only t e t o n e PCH pleas n every ble i d e d u incl plica d as ap e s u e b

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20a

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

please press firmly

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

IMMUNISATION

HEPATITIS B INFANT VACCINATION PROGRAMME

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

1st Dose

Within 48 hours of birth

2nd Dose

1 month

Vaccine

Batch No

Site

Date

Signature

Venue

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

please press firmly

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

IMMUNISATION

HEPATITIS B INFANT VACCINATION PROGRAMME

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

1st Dose

Within 48 hours of birth

2nd Dose

1 month

3rd Dose

2 months

Vaccine

Batch No

Site

Date

Signature

Venue

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

IMMUNISATION

HEPATITIS B INFANT VACCINATION PROGRAMME

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

1st Dose

Within 48 hours of birth

2nd Dose

1 month

3rd Dose

2 months

Booster

12 months

Vaccine

Batch No

Site

Date

Signature

Venue

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

IMMUNISATION

HEPATITIS B INFANT VACCINATION PROGRAMME

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

1st Dose

Within 48 hours of birth

2nd Dose

1 month

3rd Dose

2 months

Booster

12 months

Serology (HBs Ag)

12 months

Vaccine

Batch No

Site

Date

Signature

Venue

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

IMMUNISATION

HEPATITIS B INFANT VACCINATION PROGRAMME

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

1st Dose

Within 48 hours of birth

2nd Dose

1 month

3rd Dose

2 months

Booster

12 months

Serology (HBs Ag)

12 months

Vaccine

Batch No

Site

Date

Signature

Venue

be not to s i e g a o : this p R, it is only t e t o n e PCH pleas n every ble i d e d u incl plica d as ap e s u e b

20f

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

please press firmly

Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

PRIMARY COURSE OF VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: .................................................................................................................................................................... Breastfeeding at 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 1 Dip/Tet/Pert Hib Polio Meningococcal C

Batch No

Dose

Site

Date

Signature

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Venue

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

PRIMARY COURSE OF VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: .................................................................................................................................................................... Breastfeeding at 1st Imm: Totally

at 2nd Imm

Totally

Partially

Partially

Not At All

Not At All

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (2) Signed..............................................................................................Date ............................... Antigen 1 Dip/Tet/Pert Hib Polio Meningococcal C 2 Dip/Tet/Pert Hib Polio Meningococcal C

Batch No

Dose

Site

Date

Signature

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Venue

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

PRIMARY COURSE OF VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: .................................................................................................................................................................... Breastfeeding at 1st Imm: Totally

at 2nd Imm

at 3rd Imm

Totally

Totally

Partially

Partially

Partially

Not At All

Not At All

Not At All

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (3) Signed..............................................................................................Date ............................... Antigen 1 Dip/Tet/Pert Hib Polio Meningococcal C 2 Dip/Tet/Pert Hib Polio Meningococcal C 3 Dip/Tet/Pert Hib Polio Meningococcal C

Batch No

Dose

Site

Date

Signature

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Venue

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

PRIMARY COURSE OF VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: .................................................................................................................................................................... Breastfeeding at 1st Imm: Totally

at 2nd Imm

at 3rd Imm

Totally

Totally

Partially

Partially

Partially

Not At All

Not At All

Not At All

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (3) Signed..............................................................................................Date ............................... Antigen 1 Dip/Tet/Pert Hib Polio Meningococcal C 2 Dip/Tet/Pert Hib Polio Meningococcal C 3 Dip/Tet/Pert Hib Polio Meningococcal C

Batch No

Dose

Site

Date

Signature

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Venue

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

VACCINATION (MMR – FIRST DOSE)

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

Batch No

Dose

Site

Date

Signature

Venue

Measles/Mumps/Rubella (1)

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

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

VACCINATION (MMR – SECOND DOSE)

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

Batch No

Dose

Site

Date

Signature

Venue

Measles/Mumps/Rubella (1)

Measles/Mumps/Rubella (2)

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

VACCINATION (MMR)

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

Batch No

Dose

Site

Date

Signature

Venue

Measles/Mumps/Rubella (1)

Measles/Mumps/Rubella (2)

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

ADDITIONAL VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: ....................................................................................................................................................................

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (3) Signed..............................................................................................Date ............................... Antigen 1

Batch No

Dose

Site

Date

Signature

Venue

2

3

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

ADDITIONAL VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: ....................................................................................................................................................................

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (3) Signed..............................................................................................Date ............................... Antigen 1

Batch No

Dose

Site

Date

Signature

Venue

2

3

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

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

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

ADDITIONAL VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: ....................................................................................................................................................................

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (3) Signed..............................................................................................Date ............................... Antigen 1

Batch No

Dose

Site

Date

Signature

Venue

2

3

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

ADDITIONAL VACCINATIONS

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: ....................................................................................................................................................................

Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (3) Signed..............................................................................................Date ............................... Antigen 1

Batch No

Dose

Site

Date

Signature

Venue

2

3

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

VACCINATION (PRESCHOOL BOOSTER)

Permanent address:............................................................................................................Postcode ........................................... GP name & address: .................................................................................................................................................................... HV name & address: ....................................................................................................................................................................

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

Batch No

Dose

Site

Date

Signature

Venue

Diphtheria/Tetanus/ acellular pertussis booster

Polio booster Other

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This copy should be returned to the Immunisation Section

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Surname ..........................................................Forenames .................................................Date of Birth...................................... NHS No. ....................................................................ID No............................................................... Sex M/F ..........................

IMMUNISATION

VACCINATION (PRESCHOOL BOOSTER)

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

Batch No

Dose

Site

Date

Signature

Venue

Diphtheria/Tetanus/ acellular pertussis booster

Polio booster Other

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

24a

This copy should remain in PCHR

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

growth charts & other information

growth charts & other information

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

FINDING OUT ABOUT MOVING

lifts head clear of ground

rolls over

sits with support

sits alone

moves around or crawls

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

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

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

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

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

stands holding on

stands alone

walks holding on

walks alone

first outdoor walk

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

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

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

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

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

GROWTH CHARTS & OTHER INFORMATION

YOUR CHILD’S DEVELOPMENTAL FIRSTS

25

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

FINDING OUT ABOUT HANDS

stares at hands

grabs and holds big things

drops things on purpose

pulls your hair

picks up small things

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

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

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

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

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

finger feeds

feeds with a spoon

holds pencil & scribbles

opens cupboards

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

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

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

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

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

FINDING OUT ABOUT HANDS

stares at hands

grabs and holds big things

drops things on purpose

pulls your hair

picks up small things

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

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

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

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

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

finger feeds

feeds with a spoon

holds pencil & scribbles

opens cupboards

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

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

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

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

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

smiles

laughs

babbles

copies noises

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

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

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

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

says “mama” – to anyone

says recognisable word

joins two recognisable words

speaks in sentences

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

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

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

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

GROWTH CHARTS & OTHER INFORMATION

FINDING OUT ABOUT WORDS

26

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

FINDING OUT ABOUT PEOPLE

stares at your face

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

moves eyes to watch you

smiles for special people

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

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

cries when you leave the room

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

holds up arms to be lifted

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

usually sleeps through the night

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

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

27

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

NOTES

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

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

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

28

All entries should be dated and signed

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

28 contd.

________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

NOTES

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

28 contd.

________________________________________________________________________________________________

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

28 contd.

________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

NOTES

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

28 contd.

________________________________________________________________________________________________

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

28 contd.

________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

NOTES

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

28 contd.

________________________________________________________________________________________________

NOTES ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

28 contd.

________________________________________________________________________________________________

All entries should be dated and signed Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Harlow Healthcare 0191 455 4286

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