MEDICAL QUESTIONNAIRE

PUPIL DETAILS

Title :
First Name :
*
Surname :
*
Gender :
*
Date Of Birth :
*
Nationality :
*
Name and Address of Parent :
*
Name and Address of Present Doctor :
*
Past Medical Problems - include Measles, Mumps, Rubella, Glandular Fever, Chicken Pox.
Problem :
Approx Year :
Medication being taken at present :
Allergies - including antibiotics and food (e.g. nuts, eggs) :
Family History - any illnesses or conditions that may run in families including Epilepsy, Diabetes, adverse reactions to anaesthetics :
Does he / she have medical / dental insurance? If so please give details :
Are there any religious considerations in respect of medical treatment? :
VACCINATIONS
Please ensure that your son / daughter is up to date with vaccinations in accordance with your current Department of Health Policy.
BCG - please indicate if already received and give date :
The following is a guide to the vaccinations received by pupils in UK. Please tick and give dates, if possible, if your son / daughter has received these.
Age Vaccine Date 1st(YYYY-M-D) Date 2nd(YYYY-M-D) Date 3rd(YYYY-M-D)
At 1,2 and 3 months
At 12 to 15 months
3 to 5 years (pre-school booster)
10 to 14 years or soon after birth
13 to 18 years School leavers
Travel and other vaccines
I Give Permission :
*
1.  In the event of injury, for my son / daughter to be given First Aid treatment
2.  For my son/ daughter to be given appropriate over the counter medication in accordance with the School Doctor's instructions on usage.