Pupil Medical Form

Pupil's Name* Pupil's Date of Birth

VACCINATION RECORD

Please give the year of the last immunisation against the following

Diptheria
Polio
Tetanus
Whooping Cough
BCG (Tuberculosis)
MMR
Yellow Fever
Cholera
Typhoid
Hepatitis
Meningitis

Any other immunisations
	Name	Year

Medical History

Has your son suffered from any of the following? If so please give approximate dates.
	Yes/No	Date
Measles
Mumps
Rubella
Chicken Pox
Whooping Cough
Tuberculosis
Asthma
Rheumatic Fever
Heart Condition
Epilepsy
Diptheria
Scarlet Fever

Any other (please give approximate dates)

Please list any medication your son is taking and the reason for it
	Medication	Reason

Is your son Asthmatic?*YesNo

What medication does he take for this?

Medical History continued.

Please list any allergies your son has Please provide full details of any operations your son has had Please list the countries your son has visited in the last 12 months

General Information
	Yes	No
Does your son wear spectacles and/or contact lenses?
Does your son suffer with nocturnal enuresis?
Is there any other medical information the College needs to know?

Please give details Name and Address of GP your son is registered at Name and Address of Dentist your son is registered at Please state your religion Date of arrival in UK (if applicable)

Confirmation*Please tick this box to confirm all information given is accurate.

Pupil Medical Form

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