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Medical Questionnaire

Please select which residential trip your child is going on: Pupil's First Name:* Pupil's Last Name:* Class: Date of Birth (dd/mm/yyyy):* Home Address:* Main Telephone No.:* Second Telephone No. :* Name & Address of Doctor Surgery:* Doctor Surgery Telephone No.:*

Medical History

Has your child ever had any of the following?*

	Yes	No
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

If the answer to any of these questions is YES please give details below:

Immunisation Status

	Yes	No
Has your child received vaccination against Tetanus in the last five years?

Date if Yes: *

	Yes	No
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?

If the answer to either of these questions is YES please give the details below:

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 medication	Dosage	Time to be administered	Details 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:

	Yes	No
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.

Form completed by: Relationship to child:* Email*

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