Student's Name _______________________________________________
Date of Birth ______/______/______
Parent's Name and Initials ________________________________________
Home Address ________________________________________________
____________________________________________________________
____________________________________________________________
Contact Telephone no. Home ____________________________
Contact Telephone no. Work ____________________________
Name and Address of Family Doctor _______________________________
____________________________________________________________
____________________________________________________________
Doctor's Telephone number ______________________________
Student's NHS No. ____________________________________
Has your son/daughter had any of the following?
Asthma or Bronchitis YES NO
Heart condition YES NO
Fits, Fainting or Blackouts YES NO
Severe Headaches YES NO
Diabetes YES NO
Allergies to any known drugs YES NO
Any other allergies, eg. Feathers or Food YES NO
Other illness or disability YES NO
Travel Sickness YES NO
Medicine YES NO
If the answer to any of these questions is YES, please give details:
_____________________________________________________________________________________
Has your son/daughter received vaccination against Tetanus in the last five years YES NO
Is your son/daughter receiving medical or surgical treatment of any kind from either your Family Doctor or Hospital? YES NO
Has your son/daughter been given specific medical advice to follow in emergencies. YES NO
If the answer to either of the last two questions is YES, please give the details here (including dosage of any medicines/tablets).
______________________________________________________________________________________
Signed:..........................................................................
Date:...................................................................... Father/Mother/Guardian