Newbury Hall Health Questionnaire

This questionnaire is to find out if there are any medical problems which may affect your child in school. It is a confidential document and is only available to school staff who have direct responsibility for your child's health and wellbeing e.g. the Headmaster, Housemistress and Centre Organiser. Only information essential to your child's safety within the school will be shared with other staff. Please help us to give the best possible care for your child by completing as many questions as you can. The school is required by law to hold medical information, including emergency contact information, for all our pupils.

Pupil Information

Full Name:

Date of Birth:

Town and Country of Birth:

Accommodation Type:

Sex:

Photo (optional):

Street 1:

Street 2:

Town/City:

Postcode:

Country:

Emergency Contact Telephone

Pupil Email:

Doctor's Information

Family Doctor's Name:

Street 1:

Street 2:

Town/City:

Postcode:

Country:

Doctor's Phone:

Parent/Guardian's Information

Parent/Guardian's Full Name:

Street 1:

Street 2:

Town/City:

Postcode:

Country:

Parent/Guardian's Phone:

Family Information

It is helpful for us to know something about your family and the child's place in the family.

Please list the people with whome the student normally lives:

Name	Date of Birth	Occupation	Relationship to Pupil	&

If the student does not live with both parents or lives with guardians occasionally please give details

Name	Address	Relationship to Pupil	&

We are required by law to obtain contact numbers for persons who can give consent for your child in the case of a medical emergency. Please list at least two contact numbers (in the order in which they should be contacted).

Person to be Contacted	Phone Number	Relationship to Pupil	&

Medical History

Has your child had any operations, or accidents?

Yes: No:

Does your child have asthma, diabetes, epilepsy, recurrent fits or any problem which requires daily treatment?

Yes: No:

Does your child have any other long-term medical, physical or psychological problems including obesity, eating disorders, self harm or depression?

Yes: No:

Does your child have any other problems/requirements that may affect him/her while in school e.g. allergies, hayfever, eczema, travel sickness, migraines, bed wetting, soiling, etc?

Yes: No:

Does your child have any specific dietary requirements e.g. food allergies, cultural or religious practices, parental preference, etc?

Yes: No:

Is your child attending eye clinic or an ear, nose and throat specialist?

Yes: No:

Does your child require any aids in school, e.g. hearing aids, glasses, contact lenses, overlays, orthopaedic aids?

Yes: No:

Does your child see any other professionals/agencies e.g. speech therapy, occupational therapy, physiotherapy, dietician, orthodontist, etc?

Yes: No:

Has your child ever been assessed or received support/treatment from an Educational or Clinical Psychologist or a Child Psychiatrist or do you have any concerns about your child's learning needs or psychological wellbeing?

Yes: No:

Is there any reason why your child should not participate in sport including water sports?

Yes: No:

Is there anything else you feel we should know that is relevant to your child's health and/or well being, e.g. history of family illness, bereavement, parental separation, divorce etc

Yes: No:

If there is anything you would like to discuss in relation to your child's health, please give details or contact the Headmaster or email james.martin@newburyhall.com

Yes: No:

Does your child use any medication including creams, tablets, liquids, inhalers or injections regularly?

Yes: No:

Has your child had any of the following?

Measles:

Chicken Pox:

Glandular Fever:

Malaria:

Meningitis:

Mumps:

Whooping Cough:

Scarlet Fever:

Cholera:

Rubella:

Tuberculosis:

Rheumatic Fever:

Tyhpoid:

Other:

Immunisations and Vaccinations

It is essential that you list the dates your child was immunised or provide a copy of your child's immunisation record (in English please).

Immunisation	Date 1	Date 2 (optional)	Date 3 (optional)	&

If your child has not had, or is not going to have the usual childhood immunisations pleas state why (e.g., parently preference, adverse reaction).

Medicines in School

THE SCHOOL DOES NOT ALLOW ANY MEDICINES IN SCHOOL without written instructions from a registered Medical Practitioner.

STUDENTS MUST NOT UNDER ANY CIRCUMSTANCES SHARE/SWAP OR TRADE THEIR MEDICINE WITH ANY OTHER STUDENTS. Single doses of non-prescription medicines (e.g. Paracetamol, cold remedies etc) are available from the office staff during the school day and from the Residential staff during the nights and weekends and only to those students whose parents have given their consent.

BOARDING STUDENTS ARE NOT PERMITTED TO KEEP ANY MEDICINES INCLUDING HOMEOPATHIC, HERBAL OR ORIENTAL REMEDIES IN THEIR ROOM without undergoing a risk assessment by the local Medical Officer. In order to comply with UK law any unidentifiable medicine found on school premises will be destroyed immediately. All boarding houses have a supply of non-prescription medicines (e.g. Paracetamol, cold remedies etc) which are available to boarders as required.

Consent for Health Checks, First Aid, and Emergency Medical Treatment

In the event of my child being ill or injured I give permission for first aid treatment to be given by aqualified First Aider

Yes: No:

In the event of my child being unwell while in school I give permission for appropriate treatment, which may include a minimum dose of non-prescription over the counter medicines (homely remedies ), to be given by the Houseparents or office staff who are First Aid trained. (Medicines list available on request):

Yes: No:

In the unlikely event of the school being unable to contact me in an emergency, I give permission for my child to be taken to hospital to receive urgent medical, surgical or dental treatment, including x-rays and anaesthetic, as considered necessary by the relevant medical professional. NB. This action would only be taken in extreme circumstances where a delay could be detrimental to your child's health.

Yes: No:

If my child is ill, I give my permission for my child to be seen and examined by the school Medical Officer or other registered GP if necessary and to receive treatment, which may include prescription and non-prescription medication as appropriate.

Yes: No:

I give permission for my child to take part in routine health checks undertaken by the school Medical Officer (Vision, hearing and growth ) as required.

Yes: No:

NB. A GP medical assessment including urinalysis, vision, colour vision, growth and blood pressure check may be undertaken for new boarding pupils if a medical need is identified.

The school will make every effort possible to keep you informed about your child's health.

Signed (Parent/Guardian)