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Medical Questionnaire

Medical History

Has your child ever had any of the following?*
 YesNo
Asthma or Bronchitis
Heart condition
Fits, fainting or blackouts
Severe headaches
Diabetes
Allergies to any known drugs or medication
Any other allergies e.g. material, food, insect bites etc.
Other illness or disability
Any recent contact with contagious diseases and infections

Immunisation Status

*
 YesNo
Has your child received vaccination against Tetanus in the last five years?
*
 YesNo
Is your child receiving medical treatment of any kind from either your Family Doctor or Hospital?
Has your child been given specific medical advice to follow in emergencies?

Medication to be taken whilst away

Any medication that needs to be taken during the residential, must be handed to the class teacher by the parent/carer. This includes travel sickness medication. The medication should be in containers clearly labelled with the child’s name, the type of medicine and the dosage instructions. Please also complete the following:

 Name of medicationDosageTime to be administeredDetails of administration e.g. before, with, or after food.

Whilst we are away, it may be possible that your child needs Calpol (e.g. for a headache) or Piriton. Please complete the following:

*
 YesNo
I consent to my child (as named on the front) being given Calpol if deemed necessary whilst away at the residential.
I consent to my child (as named on the front) being given Piriton if deemed necessary whilst away at the residential.