HEALTH SUMMARY FOR PRIMARY SCHOOL STUDENTS

CHILD S DETAILS (to be completed by Parent/Carer)

Childs surname

Forename(s)

Sex

Date of birth (DD/MM/YYYY)

NHS Number

Address

Home phone no.

Postcode

Work phone no.

Email

Ethnicity

Language spoken at home

 
 
 

SCHOOLS

Previous school

Present school

Address

Postcode

PARENTS/CARERS DETAILS

(Please give full names of parents/carers - ensuring to include both mother's and father's details if relevant)

1st Parent/carer

Parental responsibility

2nd Parent/carer

Parental responsibility

How many children in your family / under your care

Of these

How many children attend Nursery

How many children attend primary school

How many children attend secondary school

 
 
 

IMMUNISATION STATUS (if you are unsure of any vaccinations please contact your GP)

Baby and child immunisations (please tick)

If you need help completing this section please speak to a member of the school health team

BCG

(Protects against: tuberculosis (TB). Given from birth to 12 months of age)

5 in 1 vaccine

(Protects against: diphteria, tetanus, wooping cough, polio and Hib. Given at 2,3 and 4 months of age)

Pneumococcal

(Protects against: some types of pneumococcal infection. Given at 2, 4 and 12-13 months of age)

Meningitis B

Hib/MenC booster

(Protects against: haemophilus influenza type b (Hib) and meningitis C. Given at 12-13 months of age)

Rotavirus

MMR

(Protects against: measles, mumps and rubella. Given at 12-13 months and at 3 years and 4 months of age plus)

Pre-school booster

(Protects against: diphteria, tetanus, whooping cough and polio. Given at 3 years and 4 months of age plus)

Influenza

(Aged 2 to 8 years)

 
 
 

DENTAL HISTORY

Is your child registered with a dentist?

Please note dental treatment is free for children under 16 and pregnant women with NHS dentists

Which dentist is your child registered with?

Dental practice name

 
 
 

DEVELOPMENT AND BEHAVIOUR

Have you any concerns for your child regarding the following? (please tick)

Yes

No

Anxiety

Speech

Eyesight/Squint

Sleeping

Nutrition

Clumsiness

Anger

Hearing

Weight/Growth

Behaviour

Learning

Movement

 
 
 

Does your child wear glasses?

Where did you receive the glasses from?

Is your child under the care of an eye specialist (excluding High Street Optitian)?

Does your child wear hearing aids?

Is your child under the care of an audiology or hearing clinic?

Is your child seeing a specialist or service for any of the above or other conditions?

If so, please provide contact details and date last seen in the box provided.

 
 
 

TOILETING

Does your child wet the bed at night?

Does your child regularly wet themselves during the day?

Does your child have any problems with soiling?

Does your child have any problems with constipation?

MEDICAL HISTORY

Has your child been diagnosed with asthma by a doctor?

If yes, has your child been prescribed an inhaler?

If yes, what is the name of the medication?

Has your child been diagnosed with an allergy by a doctor?

Please specify what they are allergic to

Please state any medication your child has

been prescribed for their allergies

 
 
 

MEDICAL HISTORY (continued)

Is your child currently being treated for any of the following? (please tick)

Diabetes

Eczema

Epilepsy

Sickle cell

Other conditions?

Is your child currently under the care of a specialist or consultant

for any of the above or other conditions in the last year?

Has your child ever been admitted to hospital?

If yes, what for?

When?

Where?

Has your child ever had an operation?

If yes, what for?

When?

Where?

Does your child need to take any medication during school hours

or requires emergency medication?

If yes please state what medication your child has been prescribed

Please state any medication your child takes regularly

 
 
 

HEALTH CONCERNS AND ADDITIONAL INFORMATION

Are there any health concerns other than the above with your child

that you wish to discuss with the School Nurse?

If yes please give details

Do you give consent for health screening results e.g. hearing

and vision to be shared with relevant teaching staff at school?

Did your child have a health care plan

at their previous school/ nursery?

Please click submit to complete the form. This will help in meeting your childs educational needs.

Created by KeyPoint survey software