Pupil Medical Form
This form includes sensitive information and must be treated as confidential.
Child's Name *
Child's DOB *
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DD
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Medical Diagnosis/Condition/Allergy (please provide as much information as you can) *
Date of Diagnosis/Condition/Allergy *
MM
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DD
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YYYY
If applicable, next review date of Diagnosis/Condition/Allergy
MM
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DD
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YYYY
Clinic/Hospital *
Telephone Number *
I have emailed a copy of a medical letter to confirm condition/diagnosis/allergy to admin@caltonprimary.co.uk *
Describe medical needs and give details of child’s symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc. *
Name of medication, dose, method of administration, when to be taken, side effects, contradictions, administered by/self-administered with/without supervision if applicable
Name of medication, dose, method of administration, when to be taken, side effects, contradictions, administered by/self-administered with/without supervision if applicable
Daily care requirements if applicable
Special arrangements for school visits/trips if applicable
Any other information you feel the school may need
Name of Parent/Carer *
Relationship to Child: *
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