Medical Questionnaire

Student First Name*

Student Surname*

Has your child had any of the following :

Asthma or Bronchitis
Heart condition
Seizures, fainting or blackouts
Severe headaches
Diabetes
Allergies to any known drugs or medication
Any other allergies e.g. materials, food, insect bites etc.
Other illness or disability
Any recent contact with contagious diseases and infections

If answer to any of these questions is yes please give details

Is your child receiving medical treatment of any kind from either your Family Doctor or Hospital?*

Yes
N0

Has your child been given specific medical advice to follow in emergencies?*

Yes
No

If the answer to either of these questions is YES please give the details below: (including dosage of any medicines/tablets)

Medicine

Any medicines that need to be taken during the school day must be handed to reception. The medicines should be in containers clearly labelled with the child’s name, the type of medicine and the dosage instructions. Please complete ‘Parental Agreement for Setting to Administer Medicine’ form for medication stored at school. (Available from reception)

Name

This field is for validation purposes and should be left unchanged.

Medical Questionnaire

Medical Questionnaire

Medicine

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