Health Induction Form

Student Health Questionnaire Form (Private and Confidential)

This form must be completed before arrival to Manchester.

To help us support your daughter/son with their health whilst in our care please answer the questions below.

If your daughter/son wishes to speak to someone about any personal issues please let us know in advance or on arrival that they would like to talk to someone from the senior pastoral team.

Family Name / Surname

First Name

Date Completed

Immigration Health Surcharge Reference Number

This will be on your visa. If you do not have it, this field can be completed on arrival.

Date of Birth:

GenderMaleFemale

Age on Arrival

Your weight in kilograms and your height in centimetres

Please answer the following medical questions

If you answer yes to any questions, please give further details in the box at the bottom of the form

Does your son / daughter have any medical conditions *

• Yes
• No

Does your son / daughter take doctor prescribed medication for anything? *

• Yes*
• No

* If yes please send doctor diagnosis report / psychiatric report of diagnosis and medication treatment with your son/daughter.

Has your son / daughter had any serious illnesses? *

• Yes
• No

Has your son/ daughter had a serious accident? *

• Yes*
• No

*please provide details about when the accident was, whether they had to go to hospital and if so how long they stayed in hospital and the treatment received.

Does your son / daughter have allerigies to anything? (pollen, nuts, insect bites or stings, food, medicine) *

• Yes*
• No

*What symptoms do they have and how are they treated? Have they been prescribed an emergency EpiPen?

Does your son / daughter have diabetes?

• Yes*
• No

*If diabetes has been diagnosed, is it

• Type 1
• Type 2

Please provide details of how this is managed and what has been prescribed from your doctor.

Does your son / daughter have asthma?

• Yes*
• No

*Do they have an inhaler prescribed by a doctor? Please complete and sign emergency inhaler consent form.

Does your son /daughter have any dietary requirements?

• Yes*
• No

For example Do they eat pork? Will they observe Ramadan? Halal meat? Dairy or gluten free?

Does your son / daughter wear glasses or contact lenses?

• Yes*
• No

Date they last visited the Optician

Does your son/daughter have a healthy teeth?

• Yes
• No

Please let us know if they wear a brace for their teeth.

Date they last visited the dentist

Does your son / daughter have any hearing loss?

• Yes
• No

Please let us know if your son/daughter has any aids / implants to help with hearing.

Has your son/daughter had Malaria?

• Yes*
• No

* please let us know when and what treatment they received.

Has your son/daughter had the BCG/TB test or Chest x-ray for tuberculosis?

• Yes
• No

Has your son / daughter had any heart problems and if so are they ongoing? *

• Yes
• No

Does your son/daughter have any physical health needs / injuries that prevent them from playing sport?

• Yes
• No

Does your son/daughter have problems sleeping? *

• Yes
• No

Does your son/daughter have problems with exam pressure?

• Yes
• No

Does your son/daughter have any learning needs or take medication for a specific learning condition? *

• Yes*
• No

*Was this diagnosed by a doctor? is so please send the medical / psychiatric report of diagnosis and treatment plan.

Has your son / daughter had wellbeing support from anyone other than family or teachers for their wellbeing? *

• Yes
• No

Does your son/daughter have dizziness or fainting spells? *

• Yes*
• No

*Are these Epilepsy or seizures? Are they treated by a doctor? Do they have prescribed medication to take?

Would you like your son/daughter to have any additional immunisations if they are available?

• Yes
• No

Does your son/daughter smoke cigarettes or vapour device? *

• Yes
• No

If you have answered yes to any of the above questions, please provide further details here

Do you have any other relevant health information you would like to share with us? (please details below)

We ask for medical, allergy or dietary information solely to make the necessary health and safeguarding arrangements while your child is in our care. We will store all the information provided on our secure systems for as long as your child is attending the school, but we need your consent for the information.

I agree to Abbey College Manchester having the above medical related data on my child

• agreed

Name of parent *

Full name of child *

Signature of Parent *

Clear Signature

Date

Disclaimer

I agree that the information I have given is a complete record of my daughter/son’s medical history including any medication they are prescribed to take by a Doctor, and I have included any relevant documents relating to their history or medication I believe necessary. I consent to any medical/dental/mentoring/therapy or counselling necessary for their wellbeing whilst a student at Abbey College Manchester.

MEDICAL CONFIDENTIALITY

Abbey College Manchester undertakes to respect the confidentiality of medical information and only to pass this information to members of staff who ‘need to know’ so that appropriate care can be provided. This medical form will be made available to the Personal Tutor of each student, as well as to senior staff who have a welfare role. In accordance with the College professional obligations, medical information about students, regardless of their age, will remain confidential. However, in providing medical and nursing care for a student, it is recognised that on occasions the College may liaise with the senior staff who have a welfare role, Personal Tutors, and Parents / Guardians, and that information, ideally with the student’s prior consent, will be passed on as necessary. With all medical and nursing matters, the College will respect a student’s confidence except on the very rare occasions when, having failed to persuade that student, or his/her authorized representative, to give consent to divulgence, the College considers that it is in the student’s better interests or necessary for the protection of the wider College community, to breach confidence and pass information to a relevant person or body.

By signing this form I show my consent to the medical confidentiality and I declare all the details given are correct.

Signature of student *

Clear Signature

Date

Name of parent *

Signature of parent *

Clear Signature

Date *

Submit

IMPORTANT NOTES: 

1. If your child has to receive any medical treatment in hospital the college will contact you to gain your permission before this takes place
2. Students living in college arranged accommodation will be registered with a local doctor surgery as soon after arrival as possible
3. It is the responsibility of students living outside college accommodation to register themselves with a doctor surgery. If any help in this is required please contact the college nurse
4. We aim to ensure that students do not bring medicines from their home country unless
   prescribed by a doctor and with full medical documentation detailing the medication, reason
   prescribed, dosage and dispensing regime. All undisclosed medications including any prescribed which the paperwork (copy of prescription and report for why needed) has not been given to the College Nurse on arrival if not before, (including supplements and vitamins) of any kind which are found, will be confiscated, destroyed and the student’s place in the school will be reviewed.
5. We ask that you do not send your child with any non-prescription medicines/supplements/herbal or homeopathic remedies. Anything your child needs will be supplied by their UK Registered Doctor.
6. If you do send medications/vitamins/supplements/herbal/homeopathic remedies please be aware they will be removed from the room, put into labelled bags and disposed of at a local Pharmacy. If your daughter or son returns home with UK medications these will be given to them to bring back to you. (Note there may be a charge to destroy any none UK medications, as the pharmacies now make us pay to have non-UK registered medications of any description destroyed, which could be up to £20 for each item).
   This is done for safety reasons, and Abbey College Manchester will not accept responsibility for any undisclosed medications found in student’s possession or that they take without our knowledge

 If you have any questions for the college nurse, please e-mail Amanda.Shepherdson@abbeymanchester.co.uk