St Andrew s College Medical Questionnaire.
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- Roxanne Nichols
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1 Page 1 of 5 St Andrew s College Medical Questionnaire. It is important that you answer all questions in full. Where possible any supporting medical documents should be sent with this form. Failure to disclose any illness will breach the conditions of the application. Surname: Forenames: Date of Birth (dd/mm/yy) : Religion Sex : Male Female PART 1 PRESCRIPTION MEDICATION Does your child take any regular medication (which he/she will bring with him/her?) Yes No If yes, please give details Tick one of the below I would like the House Manager to administer my child s medication and give my consent for them to do so. I believe my child is able to administer their own medication and give my consent for them to do so. EMERGENCY MEDICAL TREATMENT In case of a medical emergency, every effort will be made to contact the child s parent or guardian as quickly as possible. If your child needs an emergency operation, do you give permission for the Director of the school to sign the necessary consent form? Yes No If you have ticked No, please advise what action should be taken? DIETARY REQUIREMENTS Halal Vegetarian Kosher Vegan Gluten Free Nut free Lactose Free No beef Other (please state) Does your son/daughter have any specific learning difficulties i.e. Dyslexia. Dyspraxia, Attention Deficit (Hyperactivity) Disorder or Dyscalculia Yes No Details All students should now complete Part 2
2 Page 2 of 5 PART 2 to be completed by all students/parents if student is under 18 years of age. Please note that halls of residence are available only to NON smokers. Please confirm that your son /daughter/you (in the case of over 18s) are a non smoker. Yes No Please ensure you have ticked Yes or No. Signature Name.. Please answer all of the following questions by ticking the box Yes No 1 Are you regularly attending a hospital, community clinic or seeing a doctor? Are you suffering from or have you ever suffered from: Yes No 2 Any conditions relating to your heart or circulation? 3 Any respiratory problems? (e.g Asthma) 4 Any psychological problems? (e.g Eating disorder /depression / self-harm) 5 Any eyesight condition that cannot be corrected by wearing spectacles or contact lenses? 6 Any ongoing hearing problems or ear disorders? (e.g Tinnitus) 7 Any ongoing bone, muscle or joint problems? (e.g Recurrent back pain/arthritis) 8 Any skin diseases or conditions that require medical treatment? 9 Any gastro-intestinal or abdominal problems? (e.g Hernia/Gall Stones) 10 Any blood or metabolic disorders? (e.g Anaemia/Diabetes) 11 Any neurological conditions? (e.g severe headaches/vertigo/epilepsy) 12 Any long term or debilitating illness? (e.g Multiple Sclerosis) IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS ON PART2, YOU MUST NOW COMPLETE THE REMAINING SECTIONS OF PART 3. If you have answered NO to all the questions in PART 2 please sign and date at the end of the questionnaire.
3 Page 3 of 5 PART 3 Heart and Circulation Yes No Details (b) (d) Heart attack Angina Other heart disease, or abnormal heart rhythm Chest pain Stroke / mini stroke High blood pressure Palpitations Respiratory Yes No Details Shortness of breath or coughing (b) Bronchitis Asthma (d) Any other lung disorder Do you smoke? Psychological health Yes No Details Nervous breakdown, panic attacks, phobias, neurosis (b) Psychosis, schizophrenia, obsessive/compulsive disorder Anxiety, depression (d) Severe stress Eating disorder Have you ever tried to harm yourself? Eyesight Yes No Details Eye disease, infection, inflammation, bleeding (b) Glaucoma, disease of the retina Have you undergone any eye surgery Hearing Yes No Details Are you aware of any hearing problems? (b) Non infective ear disorder (e.g. tinnitus, vertigo) Infective ear disease (e.g. discharge, glue ear) (d) Hearing loss
4 Page 4 of 5 Gastro-Intestinal/Abdominal Yes No Details Hernia (b) Any bowel problems (e.g Colitis, chronic diarrhoea, Irritable Bowel Syndrome, Crohns, Gall stones, pancreatitis, (d) Jaundice or Hepatitis A Kidney problems, renal stones Chronic indigestion, stomach, peptic or duodenal ulcers Infections (e.g. typhoid, paratyphoid fever, salmonella, cholera) (h) Recurring abdominal pains, gynaecological problems (i) (j) Severe problems with appetite or digestion Frequent need for the toilet or incontinence Blood/Metabolic disorder Yes No Details Any blood disorder, disorder of lymph glands, anaemia, leukaemia (b) Any congenital disorder manifested through the blood? Any disease carried through the blood (e.g. Hepatitis B.) (d) Thyroid, pituitary or hormone disorder Diabetes Mellitus If yes, do you require insulin injections on a strict timetable Neurological Yes No Details Headaches, cluster headaches, migraines If yes, please indicate severity (mild, moderate or severe, and how often you get them.) (b) Severe head injury/concussion Fits, blackouts, fainting, loss of balance, double vision, vertigo (d) Epilepsy
5 Page 5 of 5 General Medical Yes No Details Cancer (b) Have you ever had a tropical disease? (e.g. malaria) Other debilitating illnesses (e.g multiple sclerosis, Parkinsons disease) (d) Do you suffer from any medical condition affecting your sleep? (if yes, please give details) (h) Have you ever had any medical condition not mentioned above that has involved your G.P., a hospital or specialist? Allergies Operations Are you currently taking any prescribed tablets or medication or receiving injections (If yes, please specify type and timetable) I certify that I have answered all questions to the best of my ability and knowledge. This should be signed by the parent where the student is under 18. Signed : Date: / / Print Name: St Andrew s College will organise if requested access to specialist services for mental health issues however, the student and family will be liable for any costs involved.
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Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK