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Medical Action Plans
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Email
*
Your email
Student Name
*
Your answer
Year Group Joining
*
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
Other:
Asthma
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Yes
No
Asthma Information including: Asthma type, Pump type, Triggers, Medication and any other useful information.
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Your answer
Allergies
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Yes
No
Other:
Allergies information including: Allergic to, controlled medication/ EPI pen and any other useful information.
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Your answer
Epilepsy
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Yes
No
Does she/he have an Epi Pen/Meds?
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Your answer
When was the last time they had a fit and how long did they last?
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Your answer
Has there been anything that can trigger a fit and what are the initial signs of a fit?
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Your answer
How quickly will this escalate to a fit and how long would a fit usually last?
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Your answer
Has she/he ever been hospitalised?
*
Yes
No
Other Medical Conditions?
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Your answer
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