1 Year Medical Form September 2015 - July 2016

1 YEAR MEDICAL FORM SEPTEMBER 2015 - JULY 2016
Appendix 3  
STOKE-ON-TRENT CITY COUNCIL                                 EDUCATION AND LIFELONG LEARNING DEPT
 
Medical Questionnaire
To be completed by the parent/guardian
 
Name of Child ......................................................................................Date of Birth .......................................................
 
Address..............................................................................................................................................................................
 
........................................................................................................Telephone number.....................................................
 
School/Youth Club attended.............................................................................................................................................
 
National Health Number....................................................................................................................................................
 
Telephone number where you can be contacted in case of emergency............................................................................
 
Name of child's doctor......................................................................................................................................................
 
Doctor's address and telephone number ...........................................................................................................................
 
..........................................................................................................................................................................................
 
IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS "YES", PLEASE GIVE FULL DETAILS OVERLEAF
 
Please ring the appropriate answer:
1  Is your child receiving any medical treatment at present?........................................................................YES/NO
2 Has your child been in contact with anyone suffering from an infectious disease
   in the last three weeks?.............................................................................................................................                YES/NO
3 Has there been any diarrhoea and/or vomiting during the last seven days ...............................................YES/NO
4 Does your child suffer from:                          
a) epilepsy.............................................................................YES/NO
b) diabetes.............................................................................YES/NO
c) asthma...............................................................................YES/NO           
d) hayfever...........................................................................YES/NO
e) bedwetting........................................................................YES/NO                                                                                         
f) any foot infection e.g. verruca..........................................YES/NO
g) allergies............................................................................YES/NO
 
5 Has there been any serious illness in the last three months?........................................................................YES/NO
6 Are there any restrictions upon physical activities?.....................................................................................YES/NO
 
Has your child received an anti-tetanus injection?  If "yes", give date...........................................................................
 
I hereby give permission for my child to receive proprietary medications and all necessary treatment, including anaesthetic, in case of emergency.  I declare that I have answered all the above questions to the best of my ability and have not knowingly withhold any information regarding physical fitness.
 
;............................................................................................................................................................................................
Signature of Parent/Guardian (after completing overleaf)                                                Date
 
This Medical Questionnaire when completed by the parent/guardian, should be returned to the Headteacher / Youth Leader.  The completed certificate will be taken on the visit by the party leader.                  
     
 
Visit:
                                                                                    Appendix  3
 
THIS SECTION TO BE COMPLETED ONLY IF THE ANSWER TO ANY QUESTION OVERLEAF IS "YES".
 
  1. Give details below of any medical treatment being received at present.If medication is being given, please ensure that sufficient supply is carried to last the duration of the course.
     
     
     
     
     
  2. Nature of infectious diseases and how contracted during the past three weeks.
     
     
     
     
     
     
  3. Further information regarding diarrhoea during the past seven days.
     
     
     
     
     
     
  4. If your child suffers from EPILEPSY, DIABETES, ASTHMA or HAY FEVER, please give FULL DETAILS BELOW.These should include severity and frequency of attack, approximate date of the last attack and details of any medication taken regularly or kept for emergencies.
     
    Bed-wetting - arrangements must be made by the parent to provide suitable bedding which may be necessary in this event.
     
     
    Foot infection - please give details:
     
     
     
  5. Please give details of the nature and date of any serious illness during the last three months:
     
     
     
     
     
     
  6. Further details of restrictions upon physical activities in school:
     
     
     
     
     
     
     
  7. Details of allergies, including reaction to painkillers, antibiotics, analgesic and other proprietary medication (and anaphylactics).
     
     
     
     
    The child's doctor may be contacted regarding the above information, and in serious cases this could result in the child being unable to attend certain courses.