Year 6 School Health Review Questionnaire :: Medway Community Healthcare

Child's name *Required

Date of birth *Required

Address *Required

Primary school: *Required

Allocated secondary school:

GP: *Required

Name of parent/carer completing for this child *Required

Relationship to child? *Required

Do you have parental responsibility for this child? *Required

If no, please provide further information

Parent/carers contact telephone number: *Required

Parent/carers email address: *Required

Do you consent to us contacting you by: *Required

Health Information

Is your child registered with a dentist? *Required

Yes

No

Is your child registered with an optician? *Required

Yes

No

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

Yes

No

Don't know

Does your child have any of the following?

Epilepsy *Required

Yes

No

Asthma *Required

Yes

No

Severe allergy requiring emergency medication *Required

Yes

No

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

Yes

No

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

Do you have any concerns for your child’s emotional wellbeing? *Required

Yes

No

Is your child a young carer? (A young carer is a child under 18 who helps to look after a relative with a disability, illness or mental health condition) *Required

Yes

No

Do you have any concerns regarding your child’s health and transition to secondary school? *Required

Yes

No

Do you have any concerns regarding your child’s health and development including puberty/growing up, maintain their own personal hygiene, continence (bedwetting), sleep, healthy lifestyles. *Required

Yes

No

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

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 6 School Health Review Questionnaire

Please only complete if your child is in year 6 and attending a school in Medway. Please complete all the questions below, even if you do not have any health concerns, and submit the form as it allows us to update your child’s details.

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Service Users, Families, Friends and Carers

Health, Care and Education Professionals

Work for us

Year 6 School Health Review Questionnaire

Please only complete if your child is in year 6 and attending a school in Medway. Please complete all the questions below, even if you do not have any health concerns, and submit the form as it allows us to update your child’s details.

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