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SCHOOL HEALTH QUESTIONNAIRE - CONFIDENTIAL 2021
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:
Registerd 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:
PRIVATE & CONFIDENTIAL – SCHOOL HEALTH QUESTIONNAIRE TRANSFER IN
Please tick Yes/No
Please use the Box below to add any comments or tell us what you would like to discuss.
Please share the names of any professionals involved in your child’s healthcare:
***
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 mental health?
Please tick Yes/No
Yes
No
3a
Do you have any concerns with your child’s behaviour?
Please tick Yes/No
Yes
No
3b
Is your child aware of road safety?
Please tick Yes/No
Yes
No
3c
Do you help to keep your child safe online?
Please tick Yes/No
Yes
No
4a
Do you have any concerns with regards to your child's growth and development?
Please tick Yes/No
Yes
No
4b
Would you consider your child to have a healthy diet?
Please tick Yes/No
Yes
No
4c
Would you consider your child achieves enough daily activity?
Please tick Yes/No
Yes
No
4b
Do you every worry your child has access to cigarettes, vaping, alcohol or drugs?
Please tick Yes/No
Yes
No
5
Does your child have any long-term medical conditions?
Please tick Yes/No
Yes
No
6
Has your child suffered a severe allergic reaction that requires medication in school?
Please tick Yes/No
Yes
No
7
Does your child have an Educational Healthcare Plan in place?
Please tick Yes/No
Yes
No
8
Are you concerned about your child's hearing?
Please tick Yes/No
Yes
No
9a
Is your child currently under the care of Audiology services or the Ear Nose & Throat Department?
Please tick Yes/No
Yes
No
9b
Are you concerned about your child's vision?
Please tick Yes/No
Yes
No
9c
Has your child see an Optician within the past year?
Please tick Yes/No
Yes
No
10
Is your child currently under the care of an Orthoptist?
Please tick Yes/No
Yes
No
11
Does your child have problems with night time bed-wetting?
Please tick Yes/No
Yes
No
12
Does your child have problems with daytime wetting or soiling?
Please tick Yes/No
Yes
No
13
Has your child had a dentist check-up in the last 12 months?
Please tick Yes/No
Yes
No
14a
Is your child up to date with all of their immunisations?
Please tick Yes/No
Yes
No
14b
Are you worried about any other health needs, that you would like your child to receive support for?
Please tick Yes/No
Yes
No
15
Would you consider your child to be a young carer?
Please tick Yes/No
Yes
No
