Student Medical Profile

Student Medical Profile
Please provide all important medical information about your child in the form below. If you have any particular concerns, you are most welcome to make an appointment with one of our medical staff to discuss things in more depth.
Student Details
Year Group
Year No.
Class
If known
First Name
Last Name
Date of Birth

DayMonthYear
Doctor Details
Family Doctor:
Doctor Name
Doctor Phone
Doctor's Surgery /Company Name
Allergies
Does your child have any allergies?
Allergy triggers
Describe what happens when your child has an allergic reaction
In the event of an allergic reaction, what actions are necessary?
Has your child been hospitalized with a severe allergic reaction?
Has your child been prescribed an Epipen?
Asthma
Does your child suffer from asthma?
Severity
Date of Last Asthma Attack:

DayMonthYear
Please list the triggers of an asthma attack:
Details of medication to be administered in the event of an attack:
Does your child require medical/hospital treatment?
Other Medical Conditions
Does your child have any medical conditions that may require emergency care?
Please provide details of the conditions that may require emergency care
Glasses/Contact lenses
Hearing impaired
Frequent nosebleeds
Travel sickness
Other medical conditions
Please list any childhood illnesses your child has had:
Medication taken on a regular basis at home:
Immunisations
Please provide the dates of your child's immunisations.

For convenience we have defaulted the Polio date to the same date as the DTP-IPV as it is generally given together. Please overwrite the Polio date if it is different.

Note: DTP-IPV is the combined vaccination for Diptheria, Tetanus & Pertussis (Whooping Cough) and Polio (IPV). You may find there are slight variations in the spelling (e.g. DTaP-IPV, dTaP-IPV).

If a tetanus booster has been given at any age, please enter the date. The booster date is required for Secondary students.
DTP-IPV (all variations):

DayMonthYear
Validation Date

DayMonthYear
Polio:

DayMonthYear
Validation Date

DayMonthYear
Tetanus booster:

DayMonthYear
Validation Date

DayMonthYear
BCG:

DayMonthYear
Validation Date

DayMonthYear
MMR:

DayMonthYear
Validation Date

DayMonthYear
Hepatitis B:

DayMonthYear
Validation Date

DayMonthYear
Varicella (Chicken pox):

DayMonthYear
Validation Date

DayMonthYear
Pneumococcal:

DayMonthYear
Validation Date

DayMonthYear
Pertussis (Whooping cough):

DayMonthYear
Other immunisations (with dates)
Medical Documents
Please upload any documents, if applicable.
Other:

Please attach any further documents if applicable e.g. hearing/eyesight results, speech therapist assessment.
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Parent Acknowledgements
Yes
Yes

The school will endeavor to contact the parent or emergency contacts should your child be ill or injured. However, if for any reason there is an emergency, I hereby give consent and full authority for the staff or agents of the school to arrange for and consent to any medical treatment or hospitalisation for my child/guardian while s/he is in the care of the school. I further authorise these staff members to enter into and execute, on my behalf, such documents or consents as may be required by Medical Practitioners, Health Care Professionals or Hospitals for such purposes.*
Parent Name

PrefixFirst NameLast Name
Parent Email
Should be Empty:

Student Medical Profile

Student Details

Doctor Details

Allergies

Asthma

Other Medical Conditions

Immunisations

Medical Documents

Parent Acknowledgements