Pupil Health Form

Child's Name Child's Date of Birth Gender Year Group Surgery Details, Address & Tel No: Doctor's Name Child's NHS Number

Has your child been diagnosed with or are you concerned about any of the following: (please include details of any medication or dietary needs in the space provided)
	Yes	No	Details
Asthma
Allergies
Epilepsy
Diabetes

Is your child taking regular medication for any condition other than those listed above?

	Yes	No	Details
Has your child ever been admitted to hospital?
Does your child suffer from any known allergies?
Does your child have a history of known visual problem?
Does your child wear glasses?
Does your child have a history of hearing problems?
Does your child have a history of ear problems?
Does your child have a history of any speech or language problems
Does your child have any speech and language therapy?
Does your child have any co-ordination problems?

Please use the space below to tell us about any other concerns you have regarding your child’s health: Please list any outside agencies involved with your child/family e.g. Occupational Therapy Service, Speech and Language Therapy Services, Social and Caring Services. (Please include dates and names if possible)

Pupil Health Form

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