Medical Information Form Medical FormΔ Contact InformationPlease fill out details here, even if contact details have already been given to the school.Child's ForenameChild's SurnameAddress Line 1Address Line 2CityStatePostcodeDOBTelephoneFormEmailArea of School- Select -Senior DepartmentJunior DepartmentNurseryEmergency ContactsPlease give details of all people to be contacted in an emergency and place them in the order you wish for them to be contacted:Name/RelationshipContact NumberName/RelationshipContact NumberName/RelationshipContact NumberPreviousNextGP DetailsSurgery NameDoctor's NameTelephoneAddress Line 1Address Line 2CityPost CodePreviousNextInfectionsHas your child had any of the following infections?Measles Yes NoMumps Yes NoRubella (German Measles) Yes NoChickenpox Yes NoPertussis (Whooping Cough) Yes NoPreviousNextImmunisationsIs your child up to date with the following immunisation?Tetanus Yes NoDiphtheria Yes NoPolio Yes NoPertussis Yes NoHaemophilus influenzae B (Hib) Yes NoMeningitis C Yes NoPneumococcal disease Yes NoMMR1 Yes NoMMR2 Yes NoRotavirus Yes NoPre-school booster Yes NoOtherPreviousNextConditionsIs there a history of any of the following?Asthma Yes NoEpilepsy Yes NoDiabetes Yes NoEar Infection Yes NoHayfever Yes NoAnaphylaxis Yes NoEczema Yes NoAllergy to Elastoplast Yes NoHearing Problem Yes NoVisual Problem Yes NoPrevious Operations Yes NoOtherPlease give further details of any of the above, if requiredSpecial Dietary Requirements?Please list ALL known allergies or sensitivities (including food allergies)Please list ALL regular or emergency medication used by your childDo you consider your child fit for all games and activities? Yes NoPreviousNextI give permission for the School to administer the first dose of Calpol (Paracetamol) suspension for pain relief and confirm that my child has received at least one dose previously without adverse effect Yes NoI give permission for the school to use Anthisan (Mepyramine) cream on my child to provide relief if necessary in the event of insect bites or stings Yes NoPrint Name (also acts as a digital signature)DateFor full details on our policy regarding the management of medicine and medical conditions within school, or to download a 'Parental Agreement for School to Administer Medication' form, please visit the school website. Previous Submit Form
