Your Child’s Health

Please complete the forms below for your child. Please note that you will not be sent an email notification after the forms are submitted. Thank you for completing them.

Health and Medical Information Form Part 1

Step 1 of 2

50%

Child's Details

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Parent/Guardian Email Address(Required)

What year group will your child joining at Bilton Grange?(Required)

What date will your child be joining Bilton Grange?

MM slash DD slash YYYY

My child has a severe allergy(Required)

Yes

My child is severely allergic to:(Required)

Bananas

Beans

Celery

Cereals

Chickpeas

Crustaceans

Coconuts

Eggs

Fish

Kiwis

Lentils

Lupin

Milk

Molluscs

Mustard

Nuts

Oranges

Peanuts

Peas

Pineapples

Sesame

Soya

Strawberries

Sulphites

Tomatoes

Other Foods

If you have selected 'other' please specify:(Required)

My child also has a moderate allergy(Required)

Yes

My child is moderately allergic to:(Required)

Bananas

Beans

Celery

Cereals

Chickpeas

Crustaceans

Coconuts

Eggs

Fish

Kiwis

Lentils

Lupin

Milk

Molluscs

Mustard

Nuts

Oranges

Peanuts

Peas

Pineapples

Sesame

Soya

Strawberries

Sulphites

Tomatoes

Other Foods

If you have selected 'other' please specify:(Required)

My child also has a mild allergy(Required)

Yes

My child is mildly allergic to:(Required)

Bananas

Beans

Celery

Cereals

Chickpeas

Crustaceans

Coconuts

Eggs

Fish

Kiwis

Lentils

Lupin

Milk

Molluscs

Mustard

Nuts

Oranges

Peanuts

Peas

Pineapples

Sesame

Soya

Strawberries

Sulphites

Tomatoes

Other Foods

If you have selected 'other' please specify:(Required)

Does your child require an adrenaline autoinjector (e.g EpiPen, Jext, Emerade)? *(Required)

N/A - No allergies

Yes

Does your child follow a specific diet?(Required)

Yes

If yes, please indicate which specific diet?(Required)

Halal

Kosher

Vegetarian

Pescatarian

Gluten Free

Lactose Free

Vegan

Other

If 'other' please specify:(Required)

GDPR

Name of Parent/Carer completing the form

Personal Data(Required)

We need to collect and retain this information in connection with our legal duty of care to keep your child safe. We will share this information with relevant staff and contractors (including, for example, caterers and those managing school trips) to the extent necessary for these purposes. Please see our Privacy Notices here for further information about how we process you and your child’s data.

I agree

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Health and Medical Information Form Part 2

Step 1 of 8

12%

Child's Details

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Date Joining School

MM slash DD slash YYYY

Year Group Joining School

Town of Birth(Required)

Country of Birth(Required)

Parent/Guardian Email Address(Required)

Doctor's details

Name of Family Doctor(Required)

Prefix First Last

Address of Doctor's Surgery(Required)

Street Address Address Line 2 City Postcode Country

NHS Number (if known)

Medical history

Please indicate if your child has or has ever had or experienced any of the following:

Has your child had any of the following childhood illnesses?

Whooping Cough

Measles

Chicken Pox

Rubella

Mumps

Any Other

If you have selected any of the above please provide further details below:(Required)

Autoimmune Diseases or disorders (eg Hyperthyroidism, Diabetes..)(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Behaviour or Developmental Disorders(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Cardiac Disease or Disorders(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Is there a history of premature heart disease in your family?(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Has there been an unexplained death due to heart disease in any immediate family members?(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Dental Issues(Required)

Yes

Please advise of the date of your last dental appointment(Required)

MM slash DD slash YYYY

If you have selected 'yes' please provide further details:(Required)

Epilepsy/ Convulsions(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Epistaxis (Nosebleeds)(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Enuresis (bed wetting)(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Fainting/ Blackouts(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Gastrointestinal Diseases or Disorders (Stomach/ Bowel)(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Haematological Disorders (Blood)(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Musculoskeletal Diseases or disorders(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Musculoskeletal Diseases or Psychological/Anxiety/Emotional Disorders(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Respiratory Diseases or Disorders(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Renal Diseases or Disorders(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Travel Sickness(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Sleep Walking(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Has your child started to menstruate?(Required)

Yes

Not applicable

If you have selected 'yes' please provide further details:(Required)

Migraine/Headaches(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Hearing Problems(Required)

Yes

If you have selected 'yes please provide further details:(Required)

Does your child require any long term medication?(Required)

Yes

If you have selected 'yes' please provide details below:(Required)

Does your child wear glasses?(Required)

Yes

If yes please advise of the date of last optician's appointment

MM slash DD slash YYYY

If you have selected 'yes' please provide further details:(Required)

Does your child wear contact lenses?(Required)

Yes

If you have selected 'yes' please provide further details:(Required)

Specialist Medical Care

Has your child ever been referred to or is your child currently seeing an external specialist?

Counsellor(Required)

Yes

If yes, please provide details(Required)

Clinical Psychologist(Required)

Yes

If yes, please provide details(Required)

Hospital Specialist(Required)

Yes

If yes, please provide details(Required)

Psychiatrist(Required)

Yes

If yes, please provide details(Required)

Psychotherapist(Required)

Yes

If yes, please provide details(Required)

Physiotherapist, Osteopath, Chiropractor(Required)

Yes

If yes, please provide details(Required)

Other(Required)

Yes

If yes, please provide details(Required)

Has your child ever had concussion?(Required)

Yes

If yes, please give dates and details of scans:(Required)

Has your child had any surgery, fractures or sports injuries?(Required)

Yes

If yes, please provide details(Required)

Medical Insurance

Does your child have private medical insurance?(Required)

Yes

If yes, please provide details(Required)

Have you opted in to the School AXA scheme?(Required)

Yes

Please indicate if your child has an allergy to:

Cats(Required)

Yes

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Dogs(Required)

Yes

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Other animals(Required)

Yes

If yes, please state which(Required)

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Environmental (dust, plants etc)(Required)

Yes

If yes, please state nature of allergy(Required)

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Bites/Stings(Required)

Yes

If yes, please state nature of allergy(Required)

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Pollen (Hayfever)(Required)

Yes

If yes, please state nature of allergy(Required)

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Please indicate if your child has an allergy to any medicines

Prescription medicines(Required)

Yes

If yes, please state which medicines(Required)

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Non prescription medicines(Required)

Yes

If yes, please state which medicines(Required)

Please confirm the severity of their allergy(Required)

Low

Moderate

Severe

Does your child require an adrenaline autoinjector (e.g EpiPen, Jext, Emerade) for any of the above allergies? (Food allergies are referenced separately)(Required)

N/A - no allergies

Yes

If yes, please state for which allergy:(Required)

Please confirm if your child has had the following vaccinations and the date on which they were administered:

BCG(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Diptheria(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Hepatitis A(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Hepatitis B(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Hib & Men C(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

HPV(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Japanese Encephalitis(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Measles(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Meningitis B(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

MMR(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Mumps(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Pertussis (Whopping Cough)(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Pneumococcal(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Polio(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Rabies(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Rotavirus(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

TBE (Tick borne encephalitis)(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Tetanus(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Typhoid(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Varicella (Chickenpox)(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

Yellow Fever(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

Date of Last Booster (if applicable)

DD slash MM slash YYYY

COVID 19(Required)

Yes

Date of vaccination(Required)

DD slash MM slash YYYY

I consent to my child receiving any nonprescription medication deemed necessary from the approved list - Paracetamol, Ibuprofen, throat lozenges, Cetirizine, Piriton, simple cough linctus, travel pills.(Required)

I consent to the administration of First Aid Treatment(Required)

I consent to the administration of Emergency Dental Treatment(Required)

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

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.(Required)

If my child suffers from any of the following I give my consent for the diagnosis to be entered onto the School computer record and a Care Plan to be created and shared as appropriate.(diabetes, asthma, epilepsy, anaphylaxis or any other significant medical condition)(Required)

I consent to my child receiving travel immunisations following a consultation to determine individual travel requirements.(Required)

Please note that any medicines brought into school must be in their original packaging with the prescription (translated into English if necessary) as per our medicine policy.

GDPR

Personal Data(Required)

I agree

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Your Child’s Health

Health and Medical Information Form Part 1

Child's Details

GDPR

Health and Medical Information Form Part 2

Child's Details

Doctor's details

Medical history

Specialist Medical Care

Medical Insurance

Please indicate if your child has an allergy to:

Please indicate if your child has an allergy to any medicines

Please confirm if your child has had the following vaccinations and the date on which they were administered:

GDPR

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