Admissions Form 2

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Admissions Form 2 - Medical

We are committed to making sure that Manchester Health Academy is a happy and successful experience for all of our children and young people. Where a child has a particular difficulty or need, we will do our best to put measures in place to overcome this. It would therefore be helpful if you could complete this questionnaire, whether or not your child has any difficulties. Please complete one form for each of your children at this school.

We will treat what you have told us here sensitively. None of the information will be shared with other parents or students. If you need help to fill in this questionnaire please let us know. Please provide supporting evidence, e.g. letter from your GP.

Student Name *

Student date of birth *

YYYY

Does the student have any of the following Medical Conditions: *

ADHD

Allergy*

Anaphylaxis

Arthritis

Asthma

Cystic Fibrosis

Diabetes

Eczema

Epilepsy

Haemophilia

Hearing impairment

Heart condition

Wears glasses

No medical conditions

Other:

Required

*If the student has an allergy/allergies, please specify:

Please indicate whether your child has any long-standing illnesses, health problems or disabilities, which mean that they have substantial difficulties with any of the areas of their life shown below? Please select all that apply.

By long-standing we mean anything that has troubled them over a period of at least 12 months or that is likely to affect them over the next 12 months. Please exclude difficulties that you would expect for a child of that age.

Mobility – moving around indoors or outdoors

Hand movements – touching or holding

Personal care – going to the toilet, dressing

Eating and drinking without help

Incontinence – wetting or dirtying

Taking medication

Communication - speaking with others, or understanding them

Learning – numbers, letters, words

Hearing

Vision

Behaviour – very active, has a short attention span, behaves unacceptably

Has fits or seizures

Diagnosed with autism or Asperger Syndrome

Has a life-limiting condition or requires palliative care

Can be depressed, or anxious, or has an eating disorder

None

Other:

Does your child take any medication, use any physical aids or require any special diet or supplements? *

Yes*

*If Yes, please provide further details:

If your child did not take their medication, use their physical aid or have their special diet or supplements, would they have substantial difficulties with any of the areas of life listed above?

Yes

Not applicable

Clear selection

Has your child seen a professional, such as a paediatrician or a psychologist or a speech and language therapist because of the difficulty?

Yes*

Not applicable

Clear selection

*If Yes, please provide further information:

Clear form

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