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Medical Survey Form

Confidential – Parental Medical Survey Form

Parental Medical Survey Form

Under certain circumstances, as a company we may require additional medical information about pupils who attend with us. This information enables us to assess any risks that pupils may face in relation to medical requirements they may have and to ensure that procedures are put in place, where possible, to lower or eliminate those risks.

Child’s name *

Child’s DOB *

School the child comes from

Your name *

Relationship to the child *

Select all that apply: *

Anaphylaxis/Allergy
Asthma
Bowel/Bladder Condition
Coeliac
Diabetes
Single Ventricle Heart Condition
Migraine
Any Other Medical Condition
No Medical Conditions

Anaphylaxis/Allergy

Reacts to: *

Please detail what substances can cause an allergic reaction/anaphylaxis in your child? Common allergens include: dairy, different types of nuts, ibuprofen, soy, pollen

Severity *

Please detail the severity of your child’s Anaphylaxis/Allergy. Can a reaction cause death or serious injury? Does your child sometimes react but the reaction subsides? In what way does your child react – swelling, rash, redness, difficulty breathing?

Is your child required to carry emergency medication? *

Yes
No

For example, an epipen.

Confirmation has been made that the child is not required to carry any emergency medication.

What emergency medication should they carry and how should it be used? *

Does your child have, and routinely carry this medication? *

Yes
No

Please explain why your child does not carry emergency medication. *

Is there anything else you need us to know about this? *

Please type “no” if there is nothing further to add.

Asthma

Severity *

Please detail the severity of your child’s Asthma. Can attack cause death or serious injury? Under what circumstances does your child have an Asthmatic episode?

Does your child need an inhaler? *

Yes
No

What type of inhaler do they carry and under what circumstances should it be used? *

Please detail why your child does not need an inhaler. *

Is there anything else you need us to know about this condition? *

Please write “no” if there is nothing further to add.

Please provide full details” *

Any Other Medical Condition

Please provide details: *

Please detail any other medical condition that we would need to be made aware of in order to keep the child safe. Please let us know any steps we need to take, things we need to think about, or medications the child needs.

The parent/carer has selected that there are no medical conditions to report. Please double check the reasons for requesting this form be completed and check with a director to sign off that there are no further actions to take.

Please sign *

Date form was completed *

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