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Reception questionnaire
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Reception questionnaire
SCHOOL HEALTH QUESTIONNAIRE - CONFIDENTIAL 2020
CHILD DETAILS
Surname:
First Name:
Address:
Postcode:
Date of Birth
NHS Number (may be found in red Child Health Book):
Boy/Girl (Delete as appropriate):
Ethnicity:
GP Surgery:
School:
PARENT/CARER DETAILS
Surname:
First Name:
Address:
Postcode:
Relationship to child:
Contact numbers:
Email address:
Do you consent to being sent health promotion
material via email:
Yes
No
Date form completed:
SCHOOL HEALTH QUESTIONNAIRE - CONFIDENTIAL 2020
Please tick Yes/No
Please use the Box below to add any comments or tell us what you would like to discuss.
***
Would you like the school nurse to contact you for any identified health needs?
Please tick Yes/No
Yes
No
1
Are you concerned about your child's
bedtime routine or quality of sleep ?
Please tick Yes/No
Yes
No
2
Do you have any concerns about your child's emotional wellbeing or behaviour ?
Please tick Yes/No
Yes
No
3a
Are you concerned about your child's hearing?
Please tick Yes/No
Yes
No
3b
Is your child currently under the case of Audiology services or the Ear Nose & Throat Department?
Please tick Yes/No
Yes
No
3c
Does your child use a hearing aid?
Please tick Yes/No
Yes
No
4a
Are you concerned about your child's vision?
Please tick Yes/No
Yes
No
4b
Is your child currently under the case of an Orthoptist?
Please tick Yes/No
Yes
No
4c
Does your Child see an Optician?
Please tick Yes/No
Yes
No
4b
Does your Child wear glasses?
Please tick Yes/No
Yes
No
5
Does your child have an Educational Healthcare Plan in Place?
Please tick Yes/No
Yes
No
6
Do you have any concerns with regards to your child's growth and development?
Please tick Yes/No
Yes
No
7
Has your Child been referred to a Dietician?
Please tick Yes/No
Yes
No
8
Does your child have an genetic conditions?
Please tick Yes/No
Yes
No
9a
Does your child have problems with Night time wetting?
Please tick Yes/No
Yes
No
9b
Does your child have problems with Daytime wetting?
Please tick Yes/No
Yes
No
9c
Does your child have problems with Soiling?
Please tick Yes/No
Yes
No
10
Does your child have any long-term medical conditions?
Please tick Yes/No
Yes
No
11
Is your child under the care of a Hospital Consultant or any other Health Professional?
Please tick Yes/No
Yes
No
12
Is your child taking any long-term prescribed medications?
Please tick Yes/No
Yes
No
13
Has your child suffered a severe allergic reaction that require medication in school?
Please tick Yes/No
Yes
No
14a
Is your Child registered with a dentist?
Please tick Yes/No
Yes
No
14b
Has your child had a dentist check-up in the last 12 months?
Please tick Yes/No
Yes
No
15
Is your child up to date with all of their immunizations?
Please tick Yes/No
Yes
No
16
Does your child take part in at least 30 minutes of physical activity every date?
Please tick Yes/No
Yes
No
17
Are there any other physical or mental health concerns within the family household that you would like support with?
Please tick Yes/No
Yes
No
