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SECTION I SELECTIVE MEDICAL EXAMINATIONS HFS 315
NAME DATE OP BIRTH
ADDRESS SCHOOL
PHONE NUMBER
FATHER'S OCCUPATION MOTHER'S OCCUPATION
1. How many children have you ? State their christian names and birthdays.
Are they all well ?
2. Has any close relative suffered from:
Asthma Tuberculosis
Diabetes Fits
3. State any illnesses or infectious diseases from which your child has suffered
or any chronic condition
4„ Is your child at present attending hospital or your own G.P. or chest Clinic ?
Yes/No If yes state the reason
5« Has your child ever been admitted to hospital for any reason ? Yes/No
If yes give details below:
Illness,Accident or Operation Age at the time Hospital
6o Has your child ever had fainting attacks, black-outs, dizzy spells, Yes/No
convulsions, fits, etc ? If yes, give details.
7» Has your child ever had ear trouble or discharging ears, or have you Yes/No
ever thought he/she might be deaf ? If yes, please give details.
8. Do you think he/she is overweight/underweight ? Yes/No
9. Is your child a poor eater, or does your child suffer from tummy Yes/No
trouble of any kind ?
10. Does your child frequently have a running nose, sore throats or Yes/No
catarrh ?
11. Does your child suffer from bronchitis or asthma or wheeziness at Yes/No
any time ?
12c Does your child seem easily tired or get unduly short of breath after Yes/No
exercise
13. Does your child wear glasses or are you concerned about his eyes ? Yes/No

Arrangements will be made for "boosters" to be given at the appropriate
time if you sign the consent form overleaf.
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