Medical Records Form

Medical Records Form

All health records will be held at the school health centre. It is essential that ALL day and boarding pupils' health records are kept up to date. This is a legal requirement that a medical welfare file remains at school with the pupil throughout their school life. It is important that the School Medical Officer is aware of the medical history of your child including details of previous illnesses, vaccinations and immunisations that have been given.
Family Name:*
Family Name
Student's Name:*
Student's Name
Student's Date of Birth*

MonthDayYear
Student Date of Birth*
DAY - MONTH - YEAR
School start date*

DayMonthYear
Date
Country of Birth*
Present Country of Residence*
Last known address in UK if applicable:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Name*
Doctor's Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Doctor's Phone Number*

Area CodePhone Number

Immunisation History
Please indicate below the dates your child's immunisations took place, if applicable.

If there is any uncertainty about this, please contact your Doctor for a printout summary of your child's medical history.

Please be aware that immunisation information will be shared with the Blackpool Teaching Hospitals NHS Foundation Trust, to ensure your child is only offered the appropriate immunisations.

Immunisation History:*

	Date Given	Given By
BCG (Birth to 12 weeks - only given in certain countries)
Primary Immunisation: 1st Diphtheria, Tetanus, Whooping Cough, Polio, HIB, Pneumococcal Conjugate (PCV), Rotavirus (8 weeks of age)
2nd Diphtheria, Tetanus, Whooping Cough, Polio, HIB, Meningitis C, Rotavirus (12 weeks of age)
3rd Diphtheria , Tetanus, Whooping Cough, Polio, HIB, Pneumococcal Conjugate (PCV) (16 weeks of age)
MMR (Measles, Mumps & Rubella), HIB, Meningitis C, Pneumococcal Conjugate (PCV) (13 months of age)
Single dose of Measles, Mumps & Rubella (13 months of age)
Pre-School Booster: Diphtheria, Tetanus, Whooping Cough, Polio (3.5 to 4 years of age)
Second dose of MMR (3.5 to 4 years of age)
HPV (Human Papilloma Virus) - 1st Dose (12 to 13 years of age)
HPV (Human Papilloma Virus) - 2nd Dose (12 to 13 years of age)
HPV (Human Papilloma Virus) - single dose vaccine post September 23
Influenza - given yearly via nasal spray or injection
Hepatitis A
Hepatitis B
Typhoid
Yellow Fever
Diphtheria (14 to 15 years of age)
Tetanus (14 to 15 years of age)
Polio (14 to 15 years of age)
Meningitis ACWY (14 to 15 years of age)

Additional comments you would like to make regarding your child's immunisation history:
Should be Empty:

Medical History