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SECTION I (contd)
14. Does your child have any rashes or suffer from any skin conditions? Yes/No
15. Does your child have flat feet or poor posture ? Yes/No
16. Does your child have any trouble with bones or joints ? Yes/No
17. Does your child wet the bed frequently ? Yes/No
18. Does your child suffer from frequent headaches ? Yes/No
19. Are there any problems connected with your child's speech that Yes/No
cause you concern ?
20. Are there any problems connected with your child's behaviour or Yes/No
general progress that cause you concern ?
21. Is there any other matter regarding your child's health you would
wish to discuss with the doctor ? If so, please give details s
22. Is there anything else you would like the School Doctor to know ? Yes/No
23. State the name and address of your Family Doctor
24. I would like my child to be medically examined whether selected or not.Yes/No
I CONSENT TO THIS EXAMINATION IF SELECTED AND SHALL/SHALL NOT BE
ATTENDING THE MEDICAL INSPECTION.
Date Signature
SECTION 2 (contd.)
Child's Name (Block letters please)
Date of Birth
School
Home Address
Telephone Number
A. * Please arrange to have my child immunised or given a booster dose against
Diphtheria, Tetanus and Poliomyelitis as required.
B. * I will arrange for my Family Doctor to immunise my child.
Date Signature
Parent or Guardian
* Please delete as applicable.
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