HEALTH SUMMARY FOR PRIMARY SCHOOL STUDENTS
CHILD S DETAILS (to be completed by Parent/Carer)
Date of birth (DD/MM/YYYY)
Home phone no.
Work phone no.
White and African
Other Ethnic Group
White and Asian
White and Caribbean
Language spoken at home
(Please give full names of parents/carers - ensuring to include both mother's and father's details if relevant)
How many children in your family / under your care
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
(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)
(Protects against: some types of pneumococcal infection. Given at 2, 4 and 12-13 months of age)
(Protects against: haemophilus influenza type b (Hib) and meningitis C. Given at 12-13 months of age)
(Protects against: measles, mumps and rubella. Given at 12-13 months and at 3 years and 4 months of age plus)
(Protects against: diphteria, tetanus, whooping cough and polio. Given at 3 years and 4 months of age plus)
(Aged 2 to 8 years)
Is your child registered with a dentist?
No (please move to next page)
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)
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.
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?
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)
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?
Has your child ever had an operation?
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.