King Alfred Medical Questionnaire – Confidential

Child's Full Name *

Date of Birth *

Year Group *

Start Date (If new pupil)

Name of Child's GP *

Address of Child's GP *

Address Line 1

Address Line 2

City

County

Post Code

GP Surgery Phone Number *

Has your child suffered from any of these conditions/illnesses? (Please comment in the box below if you wish, where indicated *

Comments on Medical Conditions above, or suffered with any other conditions not listed above

Vision

Does your child wear spectacles? *

Yes
No

Do parents wear spectacles? *

Neither
Both
One

When was your child's eyesight last tested? (Date) and what was the result *

Hearing

Please state if your child has had, or is suspected of suffering from any ear or hearing trouble e.g. discharge from ear, ear operations, grommet insertion/remove, adenoidectomy, tonsillectomy, severe ear infections, deafness. If so please give details below *

Yes
No

Details

Please state if your child has had any hospital treatment or operations or any series injuries at any time. Are there any areas concerning your child's health that you feel particularly concerned about or would like to discuss with the School Nurse, if so please give details below *

Yes
No

Details

Has the fourth (pre-school)vaccine been given for *

Is your child on any treatment, either continuously or from time to time? (Please give details below) *

Yes
No

Has your child suffered from an allergic reaction or had any serious adverse reaction to any medication? (Please give details below) *

Yes
No

Has your child suffered from any accidents or serious emotional shocks? (Please give details below) *

Yes
No

Are there any difficulties in reading and writing? (Please give details below) *

Yes
No

As far as you are aware [for young children] have there been any problems in early childhood or infancy e.g. feeding difficulties, late walking, late talking, poor bowel control, poor bladder control, overactivity? (Please give details below) *

Yes
No

Please state and give details below if your child has any behavioural issues. (Please give details below) *

Yes
No

Is there any history of physical or mental illness in the family that you think may have a bearing on your child's health? Please give details below *

Yes
No

Details of any of the above if ticked yes

Medicine/Homeopathy Consent

I consent for my above-named child to be given the following medication/remedy (as necessary) by the school nurse.

Medicines *

Ibuprofen/Ibuprofen suspension (Nurofen for children) age dependent
Calpol / Calpol 6+ (age dependent) (paracetamol suspension)
Allergy / hay fever relief (syrup or tablet — age dependent) (non drowsy — cetirizine hydrochloride or loratadine)
Piriton (chlorphenamine maleate) (may cause drowsiness — usually only used if specifically requested)
Anthisan cream (for bites and stings) (mepyramine maleate 2%)
Homeopathic remedies
None of the above

Please attach a headshot photograph of your child *

Click or drag a file to this area to upload.

Signature *

Clear Signature

Date *

Email address of parent completing the form (Once you have pressed submit you will receive a copy of the completed form) *

King Alfred Medical Questionnaire – Confidential

Vision

Hearing

Medicine/Homeopathy Consent

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