MEDICAL QUESTIONNAIRE

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Email *

Name of Child *

DOB *

YYYY

Year *

Address *

Is your child allergic or intolerant to any food or other substances? (Please give details) *

Does your child take any regular medication, including inhalers and injections, that need to be stored in school and administered. *

Yes

Does your child have any of the following conditions? *

Asthma

Diabetes

Eczema

Heart Condition

Bone Condition

Any Blood disorder

Liver problems

Epilepsy

Visual Impairment

Hearing Impairment

Has or had Cancer

Haemophilia

Kidney problems

None of the above

Required

Any condition that would mean your child is immunocompromised? *

Any other condition? (please give details) *

Does your child have any toileting issues we should be aware of? *

Yes

Has your daughter started her periods? *

Yes

Not Applicable

If your daughter has started her period, does she have any issues with them *

Yes

Not Applicable

Is there anything else you wish to tell us about your child? *

Form Submitted By *

A copy of your responses will be emailed to the address you provided.

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