Year R School Health Review :: Medway Community Healthcare

Child's name: *Required

Date of birth *Required

Address: *Required

School: *Required

GP: *Required

Name of parent/carer completing for this child *Required

Relationship to this child *Required

Do you have parental responsibility for this child? If no is selected, please provide further information *Required

Yes

No

If no, please provide more information

Parent/Carers contact telephone number

Parent/Carers email address

Do you consent to us contacting you by:

Email

Telephone

Post

Text

Health Questions

Is your child registered with a dentist?

Yes

No

Is your child registered with an optician?

Yes

No

Is your child up to date with their routine immunisations/vaccinations?

Yes

No

Don't know

Are you worried about your child’s hearing?

Yes

No

Are you worried about your child’s vision?

Yes

No

Does your child attend hospital regarding their hearing or vision?

Yes

No

Do you have any concerns regarding your child’s growth?

Yes

No

Do you have any concerns regarding your child’s toileting? This may include bedwetting, daytime wetting or constipation.

Yes

No

If you have answered yes to any of the above questions, please provide further details.

Does your child have any of the following?

Epilepsy

Yes

No

Asthma

Yes

No

Severe allergy requiring emergency medication

Yes

No

Does your child attend their GP or a hospital regularly for any health concern?

Yes

No

If you answered yes to any of the questions above, please provide further details

Are school aware of your child’s medical needs?

Yes

No

Would you like a member of the school health team to contact you regarding any of your answers? *Required

Yes

No

Support required:

Service Users, Families, Friends and Carers

Health, Care and Education Professionals

Work for us

Year R School Health Review

Even if you do not have any health concerns, please complete and submit the form as it allows us to update your child’s details.

Get in touch

Service Users, Families, Friends and Carers

Health, Care and Education Professionals

Work for us

Year R School Health Review

Even if you do not have any health concerns, please complete and submit the form as it allows us to update your child’s details.

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