Your Child's Health | School in Dunchurch

Child's Name *

First

Last

Date of Birth//

Parent/Guardian Contact Email Address *

Name and Address of Family Doctor

Town and Country of Birth *

Please provide any details of any severe illnesses during infancy or early childhood

Please indicate if your child has ever had any of the following illnesses

Asthma
Appendicitis
Bronchitis
Chicken Pox
Epilepsy
Eczema
Hay Fever
Heart trouble
Jaundice
Kidney trouble
Measles
German Measles
Ear Trouble
Sleep Walking
Mumps
Pnuemonia
Scarlet Fever
Tonsilitis
Whooping Cough
Diabetes

Checkboxes

Peanuts or other nuts
Pollen
Animals
Plants
Wasp/Bee stings
Other - please specify below

Other Allergens - please specify

Please provide details below of any operations or serious injuries.

Does your child wear glasses

Date of last Optician visit. Please note that if glasses are worn by boarders a spare kept must be kept with Matron.

When were your child's teeth last examined and please note any issues below.

Does your child have any cultural or religious dietary needs?

Does your child have any other specific dietary needs?

Please note any issues with diet or digestion

Does your child have a tendency to constipation?

Do they suffer any pain after meals?

Do they have a tendancy to wet the bed?

If you are completing this form for your daughter, has she started menstruating?

Yes
No
Not Applicable

Immunisation History

You should be able to find these dates in your child's Red Book, alternatively your GP will have a record of all immunisations.

Please confirm the date of Diptheria Vaccine

Please confirm the date of Tetanus Vaccine

Please confirm the date of Whooping Cough Vaccine

Please confirm the date of Hib Vaccine

Please confirm the date of Polio Vaccine

Please confirm the date of MMR (Measles/Mumps/Rubella)

Please confirm the date of Diptheria Booster Vaccine

Please confirm the date of Tetanus Booster Vaccine

Please confirm the date of Polio Booster Vaccine

Please confirm the date of MMR 2nd dose Vaccine

Please confirm the date of BCG Vaccine if applicable

Please provide details of any drugs/medicines that your child is taking

Is there anything about your child's physical condition which should be known before they take part in competitive sports and games?

Please give the names, addresses, telephone numbers of any consultants or surgeons who have been called in at any time over the question of your child's health.

If you wish to expand on any of your answers given above, please do so here

Is there anything else that you wish to let us know?

Boarders Only: Please send your child's NHS Medical Card or provide the number below (Overseas children will be registered with the School Doctor). The School doctor will visit the School each term to carry out a medical examination on all new boarders.

Consent to Treatment

I consent to the administration of non-prescription medicines

I consent to the administration of First Aid Treatment

I consent to the administration of Emergency Dental Treatment

I consent to the administration of normal treatments that might be prescribed by the School Doctor e.g. antibiotics or anaelgaesics

In the event that your child falls ill or suffers an injury at School please confirm your consent to the necessary treatment which may include, but are not limited to, anaesthetics, blood transfusions and any necessary surgical intervention. The School would make every effort to contact the parents in such a situation.

If you have not consented to any of the treatments listed above please provide more details below.

Parent / Guardian confirmation

Parent/Guardian Name *

First

Last

Date / Time

Email *

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Your Child’s Health

Immunisation History

Consent to Treatment

Parent / Guardian confirmation