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 *

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Doctor Details
Family Doctor: *
Doctor Name *
Doctor Phone *
Doctor's Surgery /Company Name *
Allergies
Does your child have any allergies? *

Yes No
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? *

Yes No
Has your child been prescribed an Epipen? *

Yes No
Asthma
Does your child suffer from asthma? *

Yes No
Severity

Mild: Attacks are rare, limited mostly to tightness and wheezing Moderate: Occasional attacks which can be self-managed using prescribed medication Severe: Attacks are regular, severe and have required hospital treatment
Date of Last Asthma Attack:

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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? *

Yes No
Other Medical Conditions
Does your child have any medical conditions that may require emergency care? *

Yes No
Please provide details of the conditions that may require emergency care
Glasses/Contact lenses *

Yes No
Hearing impaired *

Yes No
Frequent nosebleeds *

Yes No
Travel sickness *

Yes No
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): *

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Validation Date *

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Polio: *

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Validation Date *

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Tetanus booster:

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Validation Date

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BCG:

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Validation Date

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MMR:

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Validation Date

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Hepatitis B:

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Validation Date

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Varicella (Chicken pox):

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Validation Date

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Pneumococcal:

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Validation Date

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Pertussis (Whooping cough):

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

Upload a File
Please attach any further documents if applicable e.g. hearing/eyesight results, speech therapist assessment. Cancel of
Parent Acknowledgements
Yes *

I have completed this medical form accurately, truthfully, and to the best of my knowledge as of today's date. I understand that it is my responsibility as a parent to inform the school of any previous or new health problems or injuries and I am aware that if I have not, the school cannot be held responsible for the consequences. *
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 *

Prefix First Name Last Name
Parent Email *
Should be Empty:

Student Medical Profile

Student Details

Doctor Details

Allergies

Asthma

Other Medical Conditions

Immunisations

Medical Documents

Parent Acknowledgements