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Reception questionnaire
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Reception questionnaire
SCHOOL HEALTH QUESTIONNAIRE - CONFIDENTIAL 2022
CHILD DETAILS
Surname:
First Name:
Address:
Postcode:
Date of Birth
NHS Number (may be found in red Child Health Book):
Boy/Girl:
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 2022
Please tick Yes/No
For the School Health Team to provide accurate health support please provide additional information including the names of any professionals involved in your child's healthcare:
***
Are you concerned about your child's bedtime routine or quality of sleep?
Please tick Yes/No
Yes
No
1
Do you have any concerns about your child's emotional wellbeing or behaviour?
Please tick Yes/No
Yes
No
2
Does your child take part in less than 30 minutes of physical activity every day?
Please tick Yes/No
Yes
No
3
Are you concerned about your child's hearing?
Please tick Yes/No
Yes
No
4
Is your child currently under the case of Audiology or Ear Nose & Throat services?
Please tick Yes/No
Yes
No
5
Are you concerned about your child's vision?
Please tick Yes/No
Yes
No
6
Is your child currently under the case of an Orthoptist?
Please tick Yes/No
Yes
No
7
Are you concerned about your child's dental hygiene?
Please tick Yes/No
Yes
No
8
Does your child have an Educational Healthcare Plan in Place?
Please tick Yes/No
Yes
No
9
Do you have any concerns with regards to your child's development?
Please tick Yes/No
Yes
No
10
Do you have any concerns with regards to your child's growth?
Please tick Yes/No
Yes
No
11
Are you worried about your child's diet?
Please tick Yes/No
Yes
No
12
Does your child have problems with Night-time bed wetting?
Please tick Yes/No
Yes
No
13
Does your child have problems with Daytime wetting or soiling?
Please tick Yes/No
Yes
No
14
Does your child have any long-term medical conditions?
Please tick Yes/No
Yes
No
15
Is your child under the care of a Hospital Consultant or any other Health Professional?
Please tick Yes/No
Yes
No
16
Is your child taking any long-term prescribed medications?
Please tick Yes/No
Yes
No
17
Has your child suffered a severe allergic reaction that require medication in school?
Please tick Yes/No
Yes
No
18
Is your child missing any of their childhood immunisations?
Please tick Yes/No
Yes
No
19
Do you have any other questions about your child's physical or mental health?
Please tick Yes/No
Yes
No
