Confidential Health Questionnaire:Year 6

Please help us to help your child by completing this form.

Part 1Details about your child and other family members (please write clearly)

Full Name: / Previous Surname: / Gender
Male/Female / NHS No:
D.O.B.
Address:
Post Code: / Home Phone:
Mobile: / GP Surgery:
CurrentSchool: / Ethnicity: / Language Spoken:

Please write down the name and date of birth of parents, carers and all siblings. (Do not include childminders)

Full Name / D.O.B / Address
(if different to above) / Relationship to Child / School (if applicable) / Contact Telephone Number
Does your child have any problems with:
Day time wetting Yes/No
Night time wetting Yes/No
Constipation Yes/No
Soiling Yes/No
Talking or Speech Yes/No
Behaviour or Emotional Wellbeing Yes/No
Does your child have any medical conditions? Yes/No
Does your child receive any regular medication? Yes/No
Does your child have any allergies? Yes/No / Does your child or anyone in the household have any long term conditions that may affect your child’s school attendance? Yes/No
Are any other professionals involved with your family? Yes/No
CAMHS/Social Care/MAT Team/Other
Is your child up to date with their immunisations? Yes/No
(If NO please contact your GP)
Does your child have problems with their teeth or Yes/No
have any planned dental treatment/fillings
Is your child registered with a dentist? Yes/No
(If NO you can find a local dentist by accessing

Please tick any relevant boxes below if you have concerns about your child’s:

Vision/Eyes / Diet / Hearing / Height/Weight / Feelings/Emotions / Sleep / Other

Please provide further details if you have ticked or answered yes to any of the questions above, use additional sheet if required highlighting your child’s name and date of birth on any additional sheets used:………………………………………………………………………………………………………………………………

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Would you like any support from the School Nursing Team with regards to any concerns raised above Yes □ No □

Please visit or Derbyshire School Nursing for general advice and contact details.

Name & relationship to child: I confirm I have parental responsibility:Yes □ No □

Signature: Date ______

Your child will receive a growth review health check from the School Nursing team during year 6.

Your child’s electronic health record will be shared with other health services involved in your child’s care, If you do not agree with this please let your school nurse know.