Queen Anne’s School
Medical Information
and
Consent Forms
2012
IMPORTANT INFORMATION
It is very important that this medical information and consent form is returned to the school in respect of your daughter. This information is vital if we are to provide proper medical cover for your daughter in the event of a sudden illness or other medical emergency. For example, if your daughter has an allergy to penicillin it is very important that the School Nurse and the School Doctor know this.
Please can you provide the requested information by the first day of term when your daughter joins Queen Anne’s School. Failure to do so will mean that we are not able to accept responsibility for your daughter's health in an emergency or if she requires other medical treatment and she comes to some harm which would have been avoided if you had given us the requested information. You will also be in breach of your obligations under the School's Terms and Conditions.
Please also note the importance of providing the requested information on food allergies. Our caterers, Sodexo, need this information to ensure that your daughter will be fed safely. This information needs to be with Sodexoone week prior to the start date and accompanied by a medical certificate or doctors letter. With out this information Sodexo will be unable to produce meals for your daughter.
If emergency medical treatment is ever required, please note that although we will make all reasonable efforts to contact you in advance of treatment we cannot guarantee to do so.
Where a girl falls ill during term, the School Doctor or School Nurse may prescribe medicines for them which are administered by School staff. In this case, the School Nurse will check that medicines are being properly taken and that girls are, as a result, safe.
Occasionally, girls return from holidays and exeats with medicines prescribed by their home doctors or given to them by parents. We ask that girls hand in all such medicines to house staff. However, the School cannot accept responsibility if a girl becomes ill through taking such medicines, whether or not they are handed in to house staff, as these have not been prescribed by the School Doctor or Nurse.
Medical information
The School’s Medical Centre is staffed by a full time resident Sister, Flt. Lt. Sarah Eatwell, SRN. The school’s Medical Officer is provided by Emmer Green Surgery and the Medical Officer holds two surgeries a week at school on Tuesday and Friday.
Visiting a doctor
Usually all full-time boarders are registered with the Medical Officer. Flexi-boarders and day girls will remain registered with their own GP. Your daughter can be seen by the Medical Officer at Emmer Green Surgery, where an appointment can be made. The nature of any visits by a girl to the doctor will not be reported on. If your daughter becomes unwell during the school holidays she may be seen by your family GP as a temporary resident, thereby eliminating the need to re-register.
Medication
The School Medical Officer needs to be informed if your daughter takes regular medication and also of any treatment given during the school holidays. Any prescribed medication that is brought into school should be handed in immediately to Sister or the Housemistress, with the exception of asthma inhalers which can be kept by your daughter. All other medication will then be available to them on request via the medi-cupboard in the House or from the Medical Centre. If during the school holidays treatment is changed or a new treatment prescribed, please inform the Medical Centre on return to school.
For your information, the following medication is held in the Medical Centre and in every House and can be administered to the girls by Sister, the Housemistress and Deputy Housemistress: paracetamol, paracetamol suspension, simple linctus, milk of magnesia, throat lozenges, Olbas oil for inhalation, Deep Heat, Anthisan cream, E45 cream, witch hazel gel, TCP, assorted plasters and dressings. A record is kept of all medication given.
Day girls are expected to keep their own GPs and consult them if they become unwell and for routine immunisations. Regular medication may be handed in to Sister or their Housemistress for safe keeping. Sister is available for girls’ day to day needs.
Immunisation
While at school all boarders are offered a full programme of immunisation against infectious diseases. The purpose of this is to protect both the individual and the school population as a whole. Written permission will be sought before any immunisation is given.
It is particularly important that girls travelling abroad are fully immunised. We obtain up to date information concerning the recommended immunisations for travel to different countries and any girl who travels without adequate immunisation may be excluded from returning to school. Malaria tablets can be purchased, with written consent from parents, two weeks before travel.
Please would you therefore return the Medical History Questionnaire and the Medical Consent Form in this booklet, giving the exact dates of your daughter’s previous immunisations. Failure to do so may mean that your daughter’s immunisations are not kept up to date.
All boarders are medically examined on admission and blood tests are offered to those at risk of haemoglobinopathies, which may cause problems for them in the future.
TB Screening is now offered for all new girls coming from all risk countries.
Medical History Questionnaire / Name:Please complete this section and return to the school. Questions should be answered by Parent/Guardian of the pupil.
Date of Birth:Place of Birth:
Name and address of family GP that you are currently registered with:
(Boarders only: NHS number ______)
1. Is her general health good?
2. Is her sight perfect?
3. Is her hearing perfect?
4. Is there any physical defect to which special attention should be given?
5. Is there any reason why she should not play games?
6. Has she had the following infections? If yes, please give approximate date:
MumpsYES/NORubellaYES/NO
ChickenpoxYES/NOGlandular FeverYES/NO
MeaslesYES/NORheumatic FeverYES/NO
Please state any past/current illnesses, operations, medical problems or accidents
Is she currently undergoing or awaiting hospital treatment? YES/NO
If yes, please specify below
Medication
Is she taking any medications? If so, please provide details below, including doses.
Does she suffer from any allergies? Yes / No If yes, please complete the allergy form.
Mental health history
Has she ever suffered from depression? YES/NO
Has she ever been prescribed any antidepressant medication? YES/NO
If yes, when? ______
Has she ever had counselling? YES/NO
Has she ever been admitted to hospital or been seen in hospital outpatients with a mental health problem? YES/NO
Family history – Boarders only
Age / State of health(if alive) / Age at death / Cause of death
Father
Mother
Brother(s)
Brother(s)
Sister(s)
Sister(s)
Is there a family history of any of the following problems?
Please give details below of the member of family that has been affected by any of the following, and at what age.
High blood pressure / Angina
Heart attack / Other heart problems
Diabetes / Fits, epilepsy
Glaucoma / Cancer
Asthma / Site of cancer
Other hereditary problems ______
Signed by Parent / Guardian ______
Date ______
Immunisation
Below is the normal immunisation schedule for all people in the UK. It is particularly important that girls travelling abroad are fully immunised.
Please give exact dates of vaccinations against the following diseases.
2 months / DTP–Polio-Hib
Meningococcus Group C
3 months / DTP–Polio-Hib
Meningococcus Group C
4 months / DTP–Polio-Hib
Meningococcus Group C
12 – 18 months / MMR
4 – 5 years / DT-Polio
MMR
12 years 1 / HPVCervarix/ Gardasil
2
3
14 – 18 years / DT-Polio booster
0 – 18 years / BCG
Please give dates for: / Meningitis C
Mumps
Measles
Rubella
If flu vaccination given previously, please give date:
Influenza
Travel vaccinations: / Typhoid
Cholera
Yellow Fever
Meningitis A + C
Hepatitis A
Mono1st
2nd
Junior 1st
2nd
Hepatitis B1st
2nd
3rd
Rabies
Japanese Encephalitis
Other
DAUGHTER’S NAME (Please use capitals)
…………………………………………………………………………………………………...
Medical consent
I agree that the school’s Medical Officer may carry out immunisations to comply with the normal immunisation schedule for the UK. Written permission will be sought before any immunisation is given.
I understand that in an emergency, every effort will be made to obtain my consent to an
operation and/or administration of an anaesthetic. If this proves impossible, I hereby authorise the Headmistress or her senior deputy to act in loco parentis.
When the School Nurse deems it necessary to share medical information, such information may be shared with other members of Queen Anne’s School Staff as appropriate.
I agree that for minor illness and injury, first aid and non-prescription medicine may be given under the direction of the School Nurse or qualified First Aider. I agree for the administration of first aid and appropriate non-prescription medication to be given and permission for medical, dental or optical treatment when required.
In the event of referral of my daughter to a consultant, I should like this to be done under:
*The National Health Service
*As a private patient
(* please delete as appropriate)
Signed by Parent/Guardian______
Print name ______
Date ______
ALLERGY FORM
In order to help the school ensure a safe environment for your daughter, please provide the following information to the medical centre, where applicable.
When was the allergy first diagnosed? Please give approx date: ………………...
Approx date of last allergic reaction. ……………………...……………………..
Was diagnosis made by hospital or your GP? ……………………..………………..
Has emergency hospitalisation for an allergic reaction been needed? ..…………….
Has anaphylactic / life threatening reaction ever occurred? …………….………….
Emergency drugs prescribed in the past? e.g. Adrenaline via EpiPen,
Antihistamines……………………………………….
When was the EpiPen first prescribed? ..……………………………………………
When was the EpiPen last used as emergency? .…………………………………..
Is your daughter able to administer EpiPen to herself? ..……………………………
Where is her EpiPen kept (e.g. Person/bag/locker)? .………………………………..
Is a medi-alert bracelet worn? ……………………………………………………..
Has Piriton ever been prescribed? ………………………………………………….
When was Piriton last given in emergency? ……………………………………...
Symptoms of an extreme allergic reaction
Please tick the box if your daughter has experienced any of the list below:
Swelling or closing up of the throatDifficulty breathing; wheezing
Generalised rash or hives all over the body
Swelling of the face or lips
Floppiness or weakness
Abdominal cramps or nausea
Collapse
Please list other allergic symptoms experienced
If an EpiPen user, please provide three EpiPens to be kept at school
One to be carried by your daughter
One located in the school dining room
One located in the medical centre.
If Piriton has been prescribed, please provide medication to be kept at school.
Signed: …………………………………..
Print: …………………………………..
Date: …………………………………..
Thank you for completing the questionnaire. A comprehensive health care plan will now be made available to all staff. Please contact me if you have any questions.
PARENT’S CONSENT TO THE ADMINISTRATION OF ADRENALINE AND PIRITON 4mg BY THE SCHOOL NURSE OR VOLUNTEER MEMBER OF STAFF
Volunteer Member of Staff
This is a member of the teaching or ancillary staff (e.g. catering, administrative, house staff who have undertaken an approved First Aid Course, which has included instruction in the recognition and emergency treatment of anaphylaxis, is willing and able to administer adrenaline to a named pupil by EpiPen in an emergency.
I/We …………………………………………….agree to the School Nurse or Volunteer member of staff administering Piriton 4mg to my/our daughter …………………… should an emergency arise.
Signed: ……………………………….
Print: ……………………………….Date:…………………………….
I/We ……………………………………………agree to the School Nurse or Volunteer member of staff administering Adrenaline by means of an EpiPen to my/our daughter ……………………… should an emergency arise when an allergic reaction/anaphylaxis is suspected.
Signed: ……………………………….
Print: ……………………………….Date:…………………………….
Special Dietary Requirement Request Form
DAUGHTER’S NAME (Please use capitals)
…………………………………………………………………………………………………...
Our caterers, Sodexo, will always do their best to provide a range of healthy and tasty alternatives which take account of food allergies. Products are labelled, and notices are displayed in the dining hall explaining which products may need to be avoided by girls with particular allergies. However, in order to ensure that Sodexo take full account of any food allergies your daughter has, please ensure that the section below on allergies is fully completed and returned. The information is needed prior to the start of term to allow Sodexo to plan their menus.
Is this request for special dietary requirements the result of: (Please Circle)Medical DiagnosisReligious Beliefs
Details of Dietary Requirements:
Allergy Information (where applicable)
Details of Known Allergy:
Diagnosed by:
(Please attach a letter from the practitioner detailing the condition and any diet/information sheet received)
Signed: ……………………………….
Print: ……………………………….Date:…………………………….