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Medical Consent
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Student Name *
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Date of Birth *
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Family doctor or GP surgery
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Does your child’s health give you any cause for concern?
Is your child under any form of treatment at present?
If yes, please give details:
Your answer
Has your child ever had any eye problems?
If yes, please give details:
Your answer
Does your child wear glasses or contact lenses?
Does your child have any difficulty with hearing?
Has your child had any serious illnesses?
If yes, please give details:
Your answer
Does your child have asthma?
Is an inhaler used?
If yes, which one:
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Does your child have hayfever/other allergies?
If yes, please give details:
Your answer
Does your child have epilepsy?
Does your child have diabetes?
Does your child have any skin conditions?
If yes, please give details:
Your answer
Does your child use an autoinjector?
Does your child have any other medical conditions?
If yes, please give details:
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Is your child taking any medication?
If yes, please give details:
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Has your child had any operations?
If yes, please give details:
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Does your child have any behavioural problems?
If yes, please give details:
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Has your child had frequent or prolonged absences from school?
If yes, please give details:
Your answer
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