Skip to content
Pupil Medical Form
This form includes sensitive Information and must be treated as confidential
*
1.
Child's Name
(Required.)
*
2.
Child's Date of Birth DD/MM/YYYY
(Required.)
*
3.
Medical Diagnosis/Condition/Allergy (Please provide as much information as you can)
(Required.)
*
4.
Date of Diagnosis/Condition/Allergy
(Required.)
5.
If applicable, next review date of Diagnosis/Condition/Allergy
6.
Clinic/Hospital
7.
Telephone Number
*
8.
I have emailed a copy of a medical letter to confirm condition/diagnosis/allergy to admin@caltonprimary.co.uk
(Required.)
Yes
No
N/A
9.
Describe medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc.
10.
Name of medication, dose, method of administration, when to be taken, side effects, contradictions, administered by / self administered with/without supervision, if applicable
11.
Special arrangements for school visits/trips if applicable
12.
Any other information you feel the school may need
*
13.
Name of Parent/Carer completing this form
(Required.)
*
14.
Relationship to Child
(Required.)
Parent
Carer