Please give details of your child’s previous illnesses, operations, hospital admissions and attendance at
out-patients clinics:
________________________________________________________________________________
________________________________________________________________________________
Please tick ‘YES’ or ‘NO’ to the following: Yes No
1. Does your child suffer from any bone, joint or muscle problems?
2. Does your child suffer from any chest disease or asthma?
3. Does your child suffer from any dizzy spells or epilepsy?
4. Does your child suffer from any heart disease?
5. Does your child suffer from any skin problems
6. Does your child have a physical disability?
7. Does your child take any medication?
8. Does your child have hearing difficulties?
If so does s/he need hearing aids?
9. Does your child have poor vision? If yes:
a. Has s/he been advised to wear glasses?
b. Does your child experience difficulties in daily living?
If you have answered ‘YES’ to any of these questions, please give more details here including the name of any
medication. Please write overleaf if you need more space.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Once you have completed the form, please read the following and sign below:
I certify that I am the parent/carer of __________________________________________________ and agree to a
medical examination by the school medical officer if necessary.
Signature: ________________________________________________ Date: ______________________
(Parent/Carer)