Schools’ Screening Medical History Form
This questionnaire is intended to assist in the identification of children that may experience difficulties with hearing and sight tests.
How have you made payment? *
Required
Parent's Contact Information
Parents First Name *
Parents Surname *
Parents Email Address *
Parents Contact Number *
Best time to call *
Time
:
Address *
City *
Country *
Postcode *
Child’s Information
Name of School *
Name of Class / Form
Childs First Name *
Childs Surname *
Childs DOB *
MM
/
DD
/
YYYY
Name of Family Doctor *
first/surname
Family Doctor address / contact *
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