HEALTH QUESTIONNAIRE FOR YEAR 7 AND NEW STUDENTS ONLY
STUDENT'S DETAILS (to be completed by Student/Parent/Carer)
Who is completing this form?
Date of birth (DD/MM/YYYY)
(Please give full names of parents/carers - ensuring to include both mother's and father's details if relevant)
Home phone no.
Work phone no.
STUDENT'S DETAILS (CONTINUED)
White and African
Other Ethnic Group
White and Asian
White and Caribbean
Language spoken at home
Do you have any difficulties at home or school that are worrying you?
Do you live with your parents?
If no please state other e.g. carers, relatives, hostel, etc.
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
5 in 1 vaccine
(Protects against: tuberculosis (TB). Given from birth to 12 months of age)
(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)
Any other immunisations
DETAILS BELOW TO BE FILLED IN BY THE CHILD
(CAN BE WITH THE HELP OF PARENT/CARER)
Are you registered with a dentist?
Are you attending 6-monthly check-ups?
Please note dental treatment is free for children under 16 and pregnant women with NHS dentists
Are you concerned about your
EMOTIONAL AND PHYSICAL HEALTH
Are you experiencing problems with or would like more information about? (please tick)
Soiling / Constipation
Are you currently being treated for any of the following? (please tick)
Please provide details of your diagnosis and treatment
MEDICAL HISTORY (continued)
Have you been seen by a specialist or consultant in the past 12 months?
Name of specialist/consultant
Where were you seen?
Did you have a health care plan at your previous school?
Are there any concerns you wish to discuss with the school nurse?